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BTUDIE8  IN  GYNECOLOGY 
"1  AND  OBSTETRICS 


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McDonald 


W}.9?fM'':''. 


CialumbiaiHmbergitp 

College  of  pi)s>siitian£{  anb  burgeons; 


(giben  bp 

IBr.eiitoinP.Cragm 

1859-1918 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/studiesingynecolOOmcdo 


MJLXJtL^ 


Studies  In 


Gynecology  and  Obstetrics 


By 


ELLicE  McDonald,  m.  d. 


New  York  City 


Published  by 

AMERICAN  MEDICAL   PUBLISHING  CO. 

18  East  Forty-first  Street 
NEW  YORK 


copyright 

American  Medical  Publishing  Co., 

1914. 


INDEX 


Baby,  measuring  before  birth 48 

Bladder  troubles  in  pregnancy — a  cysto- 

scopic  study  based  on  54  cases ......  40 

Blush  of  cervix  in  early  pregnancy.  ...  33 

Catgut  ligatures,   preparation   of 28 

Catheter  cystitis  in  the  female,  preven- 
tion of 77 

Causes  of  laceration  of  the  perineum.  .  61 

Cervix,  blush  of,  in  early  pregnancy.  .  .  33 

Complications  of  placenta  previa 83 

Contractions,  uterine  in  early  pregnancy  35 

Course  and  prognosis  of  leucorrhea.  ...  18 

Cystitis  in  women,  treatment  of 10 

Cystocope,   value  of   the 10 

Cystoscopic  study  of  bladder  troubles  in 

pregnancy    40 

Diagnosis   of   early   pregnancy 29 

ectopic    pregnancy 54 

leucorrhea    18 

ovarian  pregnancy   92 

placenta  previa 85 

Duration   of    pregnancy 43 

Ectopic    pregnancy,    diagnosis    of 54 

Etiology  of  placenta  previa 82 

sterility  in  the   female.  ...  1 

Female,  catheter,  cystitis  in,  prevention 

of    77 

sterility  in  the 1 

Fibroid  tumors,  treatment  of   21 

Gonococcus  infection,  treatment  of  leu- 
corrhea due  to   17 

peurperal     infection     from 

the 2>7 

Hinge  sign  in  early  pregnancy 36 


Impregnation,    instrumental   in    sterility 

of  the  female  1 

Infection,  gonococcus,  treatment  of  leu- 
corrhea due  to   17 

puerperal,    from    the    gono- 
coccus     37 

Laceration  of  the  perineum  and  primary 
repair    59 

Leucorrhea  due  to  gonococcus  infec- 
tion, treatment  of    17 

Ligatures,  catgut,  preparation  of 28 

Measuring  the  baby  before  birth.  .....   48 

Mortality   of   placenta   previa 83 

Obstetrical   forceps,   new 23 

Ovarian  pregnancy,  with  report  of  a 
case    92 

Perineum,  laceration  of,  and  primary  re- 
pair    59 

laceration  of,  varieties  of..  62 

Placenta  previa ;  .  82 

Pregnancy,  bladder  troubles  in — cysto- 
scopic study  based  on  54  cases 40 

diagnosis  of  early   29 

duration  of   43 

ectopic,    diagnosis    of 54 

ovarian 92 

Prevention    of    catheter    cystits    in    the 

female    77 

Problem,  the  unsolved    94 

Puerperal  infection  from  the  gonococcus  Z7 

Sign,  Hinge,  in  early  pregnancy 36 

Signs,  congestive,  of  early  pregnancy.  .    32 
Skin,  sterilization  of  the 27 


Softening  of  the  cervix  in  early  preg- 
nancy       ^^ 

Sterility  in  the  female,  its  etiology  and 
treatment ;  with  report  of  a  case  of 

instrumental  impregnation   1 

Sterilization  of  the   skin    27 

Symptomatology  of  ectopic  pregnancy.    55 
Tahle  of  cases  of  laceration  of  the  per- 
ineum      66 

Treatment  of  cystitis  in  women,  with 
remarks  on  the  practical  value  of  the 
cystoscope    10 


Treatment   of   fibroid   tumors    21 

leucorrhea  due  to  gono- 
coccus  infecJtion.  .  . ..  .    17 

placenta   previa 86 

sterility    6 

Tumors,  fibroid,  treatment  of   21 

Unsolved  problem,  the   94 

Uterus,  changes  in  the,  in  early  preg- 
nancy       34 

Uterine  contractions  in  early  pregnancy  35 
Varieties  of  laceration  of  the  perineum  62 
Women,  cystitis  in    10 


STUDIES  IN  GYNECOLOGY  AND  OB- 
STETRICS. 

BY 

ELLicE  Mcdonald,  m.  d., 

New  York  City. 

CHAPTER  I. 

STERILITY    IN    THE    FEMALE;    ITS 
ETIOLOGY      AND      TREATMENT, 
WITH  REPORT    OF   A   CASE 
OF   INSTRUMENTAL   IM- 
PREGNATION. 

General  Considerations. — ^The  most  vi- 
tal instinct  is  embodied  in  the  question  of 
child  bearing  and  sterility.  The  unhap- 
piness  and  longing  of  some  sterile  women 
no  male  mind  can  fathom.  The  unsatis- 
fied maternal  instinct  is  a  misdirected,  un- 
natural expression  of  a  strong  inherent 
force.  This  instinct  is  at  best  the  most 
vitally  unselfish  of  all  desires  and  emotions 
with  which  nature  has  endowed  the  hu- 
man race.  Few  women  are  voluntarily 
sterile,  and  no  woman  exists  whom  at  some 
time  in  her  life  did  not  wish  for  a  child. 

For  these  reasons  sterility  is  in  women 
the  most  pathetic  and  touching  of  all  the 
ails  that  feminine  flesh  is  heir  to.  The 
amount  of  our  knowledge  of  its  causes  and 
of  the  processes  of  reproduction  up  to  a 
few  years  ago  have  been  ridiculously 
small :  but  more  recent  investigation  begins 
to  throw  some  light  upon  the  subject. 

The  average  interval  between  marriage 
and  the  birth  of  the  first  child  is  seventeen 
months,  and  the  probability  of  impregna- 
tion decreases  thereafter.  Only  twenty- 
five  percent,  of  women  bear  their  first  child 
after   four   years.        A   union   may   be   re- 


garded as  presumptively  sterile  when  af- 
ter three  years  of  married  life  no  child  has 
resulted.  Norris  thinks  that  this  time 
should  be  reduced,  and  that  a  union  should 
be  regarded  as  sterile  if  no  child  has  re- 
sulted within  two  years  after  marriage.  It 
may  be  that  the  truth  is  midway  between 
the  two  opinions. 

Etiology. —  Of  the  various  causes  of 
sterility  in  women,  the  chief  cause  of  the 
large  majority  of  cases  is  lack  of  develop- 
ment of  the  genitalia.  This  usually  takes 
the  form  of  the  infantile  uterus  and 
the  mal-development  may  involve  the 
vagina  and  external  vulvar  parts.  Hypo- 
plasia and  arrested  development  are  the 
usual  forms  and  it  is  frequently  hereditary. 

This  infantilism  may  exist  in  varying 
degrees.  It  may  be  associated  with  other 
evidence  of  congenital  hypoplasia,  asthe- 
nia congenitalis,  or  it  may  exist  alone  in 
the  uterus. 

When  there  are  other  evidences  of  in- 
fantilism, it  is  commonly  associated  with 
right  floating  kidney,  masculine  pelvis, 
long  back,  cannon  ball  abdomen,  intestinal 
ptosis,  proportionately  small  head,  weak 
ligaments,  high-roofed  mouths,  lobeless 
ears  and  other  evidences  of  physical  de- 
generation in  women  under  weight  and 
with  unstable  nervous  systems.  With  these 
associations,  the  infantile  uterus,  unde- 
veloped vulvar  parts  and  constricted  vagina 
are  almost  always  present.  This  type  of 
woman  begins  to  menstruate  late  in  life, 
and  ceases  early.  Their  menstruation  like 
the  rest  of  their  functions  is  subnormal, 
small  in  amount,  and  short  in  duration. 
The  premature  menopause  of  cessation  of 
the  menstruation,  between  28  and  38  years 
of  age,  is  not  infrequent  with  this  type. 

W^hile  this  is  the  extreme  type  of  in- 
fantilism   or    hypoplasia    or    asthenia    con- 


Page  One 


genitalis,  it  is  common  to  find  all  degrees 
and  minor  evidences  of  infantilism  exist- 
ing alone.  In  the  genitalia,  the  infantilism 
is  often  confined  alone  to  the  vulva  and 
vagina  or  vagina  cervix  or  uterus  alone. 
When  the  uterus  is  infantile,  it  retains 
the  shape  and  appearance  of  the  uterus 
of  the  girl  before  puberty.  It  may  take 
one  of  two  types.  It  may  be  long  and 
slender  with  a  small  fundus,  a  long  isth- 
mus and  a  long  conical  cervix,  or  it  may 
be  shorter  with  a  long  isthmus,  small 
fundus,  and  a  small  cervix  with  most  of 
the  cervix  being  placed  above  the  insertion 
of  the  vagina,  and  a  little  projecting.  The 
first  type  usually  has  a  marked  anteflexion 
and  the  second  type  is  frequently  asso- 
ciated with  a  vagina  markedly  narrowed 
in  its  upper  part. 


is  of  great  value  in  making  the  diagnosis. 
The  chief  change  is  in  lack  of  develop- 
ment of  the  labia  minora.  The  labia  ma- 
jora  are  also  small,  the  clitoris  is  unde- 
veloped  and  the  whole  vulva  gives  the  im- 
pression of  lack  of  development  and  nu- 
trition. 

This  genital  infantilism  seems  to  occur 
in  planes,  one  of  which  is  the  fundus  of 
the  uterus ;  the  second,  the  cervix  and  up- 
per part  of  the  vagina,  and  the  third  the 
lower  part  of  the  vagina  and  external 
genitals.  Any  one  of  these  planes  may 
have  lack  of  development  alone,  although 
it  is  more  common  to  find  two  planes  as- 
sociated. It  is  possible  that  when  one  is 
infantile  the  others  are  also  although  our 
methods  of   examination   cannot   detect  it. 

Genital   infantilis  in   is   the   cause    of   al- 


Fig.   1.     Starlinger's  dilators. 


The  infantile  uterus  usually  has  a  long 
isthmus  wuth  the  plicae  palmatae  of  the 
mucosa  of  the  isthmus  well  marked  and 
longitudinal  instead  of  being  thin  and  hori- 
zontal or  twisted. 

The  vagina  is  commonly  involved  in 
the  infantilism  of  the  uterus,  and  this 
takes  the  form  of  a  narrowing,  particular- 
ly of  the  upper  part  or  vaginal  lake,  so 
that  instead  of  being  balloon  or  pear- 
shaped  with  the  largest  end  upwards,  the 
vagina  is  tubular  or  sausage  shape.  As  a 
result  of  this,  the  semen  is  not  retained 
where  it  should  be  after  coitus. 

The  vulva  may  be  also  involved  in  the 
infantilism   and   it   is   here   that   inspection 


most  all  the  cases  of  sterility  in  women. 
Of  course,  there  are  many  other  isolated 
causes,  such  as  ovarian  disease,  tubal  dis- 
ease, misplacement,  perineal  lacerations, 
lactation,  thyroid  disease,  diabetes,  ter- 
tiary syphilis,  uterine  tumors,  imperforate 
hymen,  vaginismus,  etc.,  but  these  are  only 
occasional  in  their  occurrence  while  steril- 
ity is  a  common  association  of  genital  mal- 
development  and  mal-development  is  the 
chief  cause  of  by  far  the  great  majority 
of  cases  of  sterility.  It  is  essentially  lack 
of  function  from  incompetence  and  unfit- 
ness. 

One    effect    of    the    infantilism    in    the 
vagina  is  that  the  semen  cannot  readily  be 


Page  Two 


retained,  as  it  should  be  in  the  contracted 
vagina.  Fruitful  normal  women  retain  the 
semen  while  sterile  women  commonly  lose 
it.  Runge  has  shown  that  thirty-two 
hours  after  coitus  there  was  spermatozoa 
in  three-quarters  of  all  fruitful  women 
while  only  one-fifth  of  the  sterile  women 
had  spermatozoa  in  the  vagina.  At  the 
end  of  thirty-six  hours,  the  proportion  was 
two-thirds  of  the  fruitful  and  only  an  oc- 
casional sterile  woman  had  spermatozoa 
remaining. 

The  infantilism  is  not  unlike  that  atrophy 
of  the  uterus  which  sometimes  comes  dur- 
inaf  lactation.     The  best  treatment  for  in- 


tor ;  but  they  were  the  only  ones  I  have 
ever  seen  in  which  endometritis  influenced 
the  condition.  Chronic  endometritis  is  a 
rare  disease.  Chronic  endocervicitis,  which 
is  usually  meant  when  endometritis  is 
spoken  of,  is  a  common  form  of  gonococ- 
cus  infection.  It  occasionally  causes  steril- 
ity ;  but  not  often,  as  is  proved  by  the 
report  of  maternity  clinics.  Gonococcus 
salpingitis  is  a  more  common  cause  of 
sterility  although  cases  of  pregnancy  have 
been  reported  where  there  were  pus  tubes 
on  both  sides.  These  causes  are  by  no 
means  frequent,  and  I  do  not  believe  that 
the  gonococcus  is  responsible  for  nearly  as 


Fig.  2.     Stem  pessary. 


fantilism  is  pregnancy  which  increases  the 
blood  supply  and  development  and  wards 
oft  many  of  the  evil  symptoms  of  in- 
fantilism of  the  genitalia,  known  symp- 
tomatically  as  the  premature  menopause, 
neurasthenia  gastroptosis,  etc.  It  is  for 
this  reason  that  patients  in  this  condition 
should  be  encouraged  to  undergo  treatment 
for  sterility. 

The  majority  of  cases  of  sterility  are 
caused  by  infantilism  of  the  genitalia. 
Other  causes  as  before  mentioned  are  oc- 
casional ;  but  this  is  constant.  It  is  not 
believed  that  endometritis  or  alteration  in 
the  vaginal  or  uterine  discharges  play 
much  part  in  the  production  of  sterility.  I 
have  seen  two  cases  in  which  mem- 
braneous endometritis  seemed  to  be  a  fac- 


many  cases  of  sterility  in  women  as  are 
commonly  ascribed  to   it. 

But  as  has  been  said  these  causes  are 
only  incidental  and  the  chief  and  constant 
factor  in  infantilism  of  the  genitalia  or 
mal-development  or  lack  of  function  from 
genital  mal-development  or  congenital 
hypoplasia  of  the  genitalis  or  asthenia  con- 
genitalis,  all  of  which  mean  the  same  thing. 
This  condition  does  not  improve  without 
treatment.  If  the  function  is  not  exer- 
cised, it  disappears.  So  the  infantiHsm  of 
the  genitalia  without  pregnancy  or  treat- 
ment ends  in  various  nervous  manifesta- 
tions associated  with  decrease  in  menstrua- 
tion or  the  premature  menopause. 

The  prognosis  of  the  condition  must  be 
based  upon  the  local  condition  of  the  dis- 


Page  Three 


ease  and  upon  the  general  evidences 
of  infantilism.  If  the  infantilism  is  slight 
in  degree,  the  woman  otherwise  well  de- 
veloped and  the  evidences  of  function  as 
judged  by  the  menstruation  good,  the  prog- 


fat  type.      This  last  is  itself  probably  an 
expression  of  the  infantilism. 

The  local  conditions,  the  amount  and 
regularity  of  the  menstruation  are  the  chief 
factors  in  the  prognosis.     If  there  is  evi- 


Fig.  3.    Fenwick-Pozzi  operation. 

nosis  is  good.  The  general  condition  of 
robustness,  vital  force  and  general  health 
must  enter  into  the  prognosis.  Infantile 
genitalia  sometimes  may  exist  in  a  marked 
degree  in  women  who  are  of  the  athletic 
type  or  in  women  who  are  of  the  pudgily 


dence  of  the  premature  menopause,  as 
shown  by  irregularity  and  lessening  of  the 
menstruation,  this  is  not  a  good  sign  in 
the  prognosis. 

The  male  semen   should  always  be  ob- 
tained in  a  condom  or  from  the  vagma,  and 

Page  Four 


examined  before  any  treatment  is  under- 
taken. It  is  best  examined  upon  the  dark 
ground  illumination ;  it  is  probable  that 
sterility  exists  in  a  considerable  proportion 
of  men — placed  all  the  way  from  lo  to  50 


is  too  high.  Epididymitis  is  the  chief  cause ; 
but  it  is  probable  that,  of  men  having  had 
specific  urethritis,  not  more  than  six  or 
seven  percent  have  azoospermia  from  this 
cause.     Of  those  who  have  had  epididymi- 


Fig.  4.    Fenwick-Pozzi  operation. 


percent.     In  a  previous  exhaustive  paper^ 
upon  this  subject,  the  percentage  of  prob- 
able    male     sterility     was  placed     at     25 
percent.     It  is  believed,  however,  that  this 


^McDonald,     Ellice.       Sterility     in     Women. 
N.  Y.  Med.  Jour.,  1912.     Dec.  23  and  Dec.   30. 


tis  only  ten  percent  are  potent ;  but  epididy- 
mitis occurs  only  in  about  seven  percent 
of  cases  of  urethritis,  according  to 
Finger's  statistics. 

Infection      with      Neisser's      coccus      in 
women  is  not  a  frequent  cause  of  sterility. 


Page  Five 


Bumm  states  that  one-fifth  of  the  women 
deHvered  again  and  again  in  the  maternity 
suffer  from  chronic  infection  from  this  or- 
ganism. Stone  and  the  author,  found  that 
a  very  large  percentage  of  maternity  cases 


the  mucoid   discharge   may   cause   sterility 
but  not  usually. 

Treatment. — The  treatment  of  sterility 
apart  from  isolated  local  causes  is  the 
treatment     of     the     infantile     uterus    and 


suft'ered  from  this  disease, 
more  apt  to  cause  one  child  sterility  on 
account  of  its  tendency  to  spread  upwards 
after  birth  of  the  child.  The  enlarged 
cervix  of  chronic  gonococcus  infection  with 


Fig.  5.    Fenwick-Pozzi  operation 
It   is    much 


vagina. 

The  woman  should  be  put  upon  a  spare 
diet  and  reduced  if  she  is  fat.  Excessive 
fat  is  a  bar  to  conception,  as  is  well  known 
among  breeders   of   horses   and   dogs.     A 


Page  Six 


too  generous  diet  is  not  proper.     A  stated  The     sodium     -:arbonate     dissolves     the 

amount  of  exercise  is  to  be  advised.  leukorrheal  discharge  and  the  bicarbonate 

An   alkaline   douch    should   be   given    in  the   mucus, 

order  to  wash  away  the  cervical  mucus  and  The  patient  should  take  extract  of  cor- 

to  create  an  alkaline  medium  in  the  vagina  pus  luteum  as  corpora  lutea  of  beef  ovary 


Fenwick-Pozzi  operation, 
as  the  spermatozoa  live  best  in  an  alkaline     gr.  V.  t.  i.  d.  p.  c.     This  has  been  proved 


solution. 

The  following  prescription  for  powders 
put  up  in  wax  paper  is  useful. 

Sodium   bicarbonate    ^i 

Sodium   carbonate    3i 

M.  Sig.     Douche  daily  with  one  powder 
in  2  quarts  of  warm  water. 


to  be  an  ovarian  stimulant  and  to  increase 
the  genital  function  in  cases  of  deficient 
menstruation  in  the  premature  menopause. 
It  sometimes  increases  the  menstruation 
very  decidedly,  and  relieves  the  nerv-ous 
symptoms    of    the    lessened    menstruation. 


Page  Seven 


Corpus  lutetim^  has  also  been  proved  in  ani- 
mals to  have  an  influence  upon  the  em- 
bedding of  the  ovum^  and  may  do  the  same 
in  w^oraen.     It  can  do  no  harm. 

The  treatment  of  sterility,  however,  is 
chiefly  the  treatment  of  the  infantile  uterus 
and  vagina.  The  vagina  should  be  tested 
by  injecting  a  colored  gelatinous  fluid  to 
see  whether  it  is  retained.  And,  if  it  is 
expelled,  the  vagina  may  be  dilated  by  a 
pessary  while  other  procedures  are  being 
done  to   the   uterus. 

The  treatment  of  the  infantile  uterus 
must  be  that  of  development  and  dilatation 
of  the  cervix.  The  development  may  be 
done  by  electrical  treatment  with  the  con- 
stant current  or  by  the  stem  pessary.  It 
should  be  stated  here  that  mutilating  oper- 
ations should  be  a  last  resort  in  sterility, 
and  that  treatment  is  as  a  rule  most  suc- 
cessful which  causes  the  least  trauma.  At 
the  same  time,  operation  is  frequently  in- 
dicated upon  the  cervix. 

Absence  of  infection  should  be  neces- 
sary in  the  electrical  treatment  or  the  stem 
pessary.  Electrical  treatment  is  done  by 
the  constant  current  with  electrodes  which 
can  be  sterilized  about  fifty  milliamperes 
for  five  minutes  with  the  negative  pole 
in  the  uterus  two  or  three  times  a  week. 
It  regulates  the  menstruation  and  the  uterus 
increases  in  size  and  weight.  Apostoli  has 
reported  80  cases  of  conception  following 
this  treatment.  It  offers  good  results  if 
the  operator  be  patient  and  carefully  clean. 

Dilatation  of  the  cervix  may  also  be 
done  as  office  treatment;  but  it  is  unsatis- 
factory at  best. 

If  the  patient  is  more  than  slightly  mal- 
developed,  it  is  best  to  treat  her  by  dila- 
tation of  the  cervix  and  introduction  of  the 

'McDonald,  Ellice.  Corpus  luteum  in  de- 
creased menstruation  and  the  premature 
menopause.     J.  A.  M.  A.     1910.     July  16. 


Stem  pessary  under  an  anesthetic.  It  is 
hardly  possible  to  introduce  the  stem  pes- 
sary properly  without  an  anesthetic. 

The  uterus  should  be  well  dilated  with 
small  smooth  dilators  which  cause  little  in- 
jury, particular  care  to  be  taken  to  dilate 
the  upper  part  of  the  cervix  at  the  internal 
OS.  Curettage  is  not  necessary  nor  to  be 
advised.  A  previous  curettage  gives  a  bad 
prognosis  for  the  future  treatment:  it 
usually  causes  formation  of  scar  tissue  and 
lessens  the  menstruation.  There  is  no  rea- 
son Avhy  the  uterus  should  be  scraped ;  it 
denudes  itself  without  this  once  a  month. 
The  pessary  should  be  firmly  inserted  and 
sewed  in  or  kept  in  by  a  pessary  below. 
The  stem  pessary  should  remain  two  to 
three  months.  It  causes  no  trouble  at  men- 
struation and  patients  often  become  preg- 
nant while  it  is  still  inserted.  It  is  the 
most  satisfactory  treatment  for  sterility 
and  congestive  dysmenorrhea. 

This  treatment  is  usually  the  most  suc- 
cessful form  of  treatment  to  those  cases 
of  sterility  to  which  it  is  applicable ;  but  it 
should  not  be  applied  indiscriminately. 
Everything  depends  upon  a  correct  diag- 
nosis of  the  underlying  condition.  Most 
curative  procedures  are  simple  of  execu- 
tion ;  the  selection  of  treatment  is  the  only 
secret  of  medicine. 

The  choice  should  be  between  electrical 
treatment,  pessary  treatment,  operation 
upon  the  cervix  or  other  operative  and 
general  measures  alone.  This  choice  de- 
pends upon  a  knowledge  of  the  vagaries 
of  infantilism  of  the  genitalia  and  the  ef- 
fect of  this  raal-development  upon  the  re- 
productive processes. 

Operation  upon  the  cervix  is  suited  to 
certain  cases,  particularly  those  with  a 
long  hard  conical  cervix  and  marked  men- 
strual pain  and  congestion.  It  relieves 
the    severe   pain,    and    should   but    seldom 

Page  Eight 


be  undertaken  for  sterility  alone.  The  pre- 
menstrual pain  furnishes  the  chief  indi- 
cation. 

There  are  two  operations  upon  the  cervix 
which  should  be  considered.  The  bilateral 
operation  first  described  by  Fenwick  in 
1903  and  by  Pozzi  in  1909.  The  illustra- 
tions require  no  further  description.  The 
raw  surfaces  are  covered  as  far  as  pos- 
sible by  the  mucous  membrane  of  the  cer- 
vix and  the  aperture  of  the  uterus  left  patu- 
lous. This  is  the  preferable  form  of  oper- 
ation and  Fenwick  had  a  relief  of  dys- 
menorrhea in  91  percent  and  a  cure  of 
sterility  in  75  percent  of  those  cases  traced. 
Pozzi's  results  are  less  accurately  stated, 
but  he  had  fourteen  pregnancies  in  fifty 
cases  treated  both  for  sterility  and  dys- 
menorrhea. This  operation  is  the  last  re- 
sort in  sterility  from  infantile  or  unde- 
veloped uterus  with  a  long  cervix  and  as- 
sociated with  dysmenorrhea.  It  should 
never  be  done  in  the  presence  of  infection 
and  general  therapeutic  measures  and  al- 
kaline douches  should  be  used  at  the  same 
time. 

The  other  operation  is  slitting  of  the  pos- 
terior lip  of  the  cervix  of  v.  Herzl  and 
Dudley.  This  is  also  of  benefit  in  dysmen- 
or'-hea,  but  it  is  questioned  whether  it  is 
as  efficacious  as  the  previous  operation  al- 
though based   upon  the  same  principle. 

Operation  upon  the  cervix  is  not  in- 
dicated except  when  sterility  is  associated 
with  considerable  dysmenorrhea.  That 
treatment  is  most  successful  which  keeps 
the  parts  most  normal  and  mutilates  the 
least,  so,  unless  exactly  indicated,  opera- 
tion of  the  cervix  should  not  be  done. 

Instrumental  impregnation  in  certain 
few  selected  cases  is  occasionally  of  value. 
Ivanoff's  remarkable  results  in  animals 
have     increased     experimentation     in     this 


method.     He  experimented  in  guinea-pigs, 
rabbits,    dogs,    horses,    cows,    sheep,   birds 
and   mice.     He   established   the   possibility 
of   fertilizing  mammals   with  semen  in  an 
artificial    medium    entirely    free    from    the 
secretion  of  the  male  accessory  glands.  He 
found  that  the  psychic  condition  of  the  fe- 
male animal  and  the  excitement  connected 
with    copulation   had    nothing   to    do    with 
successful  conception  nor  with  the  deter- 
mination of  the  sex  of  the  offspring.     In 
his  experiments,   conception  in  horses  oc- 
curred more  regularly  with  artificial  than 
with  natural  fertilization  when  it  was  sys- 
tematically conducted,  utilizing  the  natural 
heat  and  the  most  favorable  season  of  the 
year.       Every   one   of   his   experiments   in 
horses  in  the  spring  of   1901   resulted  fa- 
vorably.      He  suspended  the  spermatozoa 
in  salt  solution,  Locke's  or  any  weakly  al- 
kaline solution.     The  spermatozoa  retained 
their  fertihzing  power  for  24  hours  after 
the  death  of  the  animal.     It  was  not  neces- 
sary to  introduce  them  into  the  cervix  as  a 
large  number  of  experiments  resulted  posi- 
tively from  the  spermatozoa  being  merely 
placed  in  the  vagina. 

These  experiments  encouraged  me  to 
make  trial  of  instrumental  impregnation. 
A  scientifically  trained  chemist,  whose  wife 
was  sterile,  asked  me  to  undertake  this 
form  of  treatment  before  any  other. 

Mrs.  B.  27  years  of  age.  Married  six  years, 
and  had  had  no  conception,  although  anxious 
for  children.  She  was  five  feet  two  inches  in 
height,  weighed  120  lbs.,  and  showed  signs  of 
congenital  infantilism.  She  had  a  right  float- 
ing kidney,  a  lobeless  ear,  a  high  roof  to  her 
mouth,  flat  feet,  double  jointed  elbows,  knees 
which  dislocated  easily,  and  was  almost  with- 
out pigment  in  the  hair  and  eyes.  Her  uterus 
was  small,  infantile  of  the  second  type  with  a 
small  cervix.  Her  vagina  was  sausage  shaped 
and  the  external  genitalia  were  infantile  and 
poorly  developed.  Her  pelvis  was  slightly  con- 
tracted and  masculine.  True  conjugate  was  10 
c.  m.  She  began  to  menstruate  at  14  j^ears  and 
menstruated  2%  to  3  days  with  moderate  flow 
and  slight  pain.  She  complained  of  backache, 
I  advised  a  stem  pessary  but,  on  account  of  a 


Page  Nine 


mitral  stenosis,  this  was  debated,  until  at  the 
solicitation  of  her  husband,  instrumental  steril- 
ization was  attempted. 

The  course  of  treatment  was  as  follows:    She 
was  put  upon  corpora  lutea  of  beef  ovary  and 
alkaline   douches.       Four  days  after  menstru- 
ation the  semen  was  brought  in  a  fish-skin  or 
parchment  condom  which  had  been  soaked  in 
normal    salt    solution.     The    condom    with   the 
resulting  semen  was  immediately  placed  in  a 
thermos    bottle — the    condom    was    allowed    to 
hang  down  into  the  water  at  a  temperature  on 
insertion  of  100°  F.     The  loose  or  open  end  of 
the  condom  was  caught  beside  the  cork.     The 
patient  took  an  alkaline   douche  and  brought 
the  bottle  to  the  office.       The  semen   was  re- 
moved  and   placed   in   Locke's   solution   to  the 
viscosity  of  thin  syrup.     The  temperature  was 
kept  about  98°  F.  by  means  of  a  water  bath. 
Injection   was   then   made   into   the   uterus   by 
means  of  a  thin  silver  canula,  bent  to  conform 
to  the  shape  of  the  uterus  and  a  glass  hypo- 
dermic syringe.     Both  these  instruments  were 
warmed  in  water  before  using.     There  was  no 
attempt    at    dilatation    of    the    cervix — nor    of 
cleansing  the  vagina  other  than   the   alkaline 
douches.     No  speculum  was  used  but  the  canula, 
full  of  the  solution,  introduced  beside  the  fin- 
ger.    The  instrument  was  passed  into  the  cer- 
vix, passed  the  internal  os,  and  about  0-60  m. 
of  solution  injected  very  slowly  and  gently  into 
the  uterus.     Care  was  taken  that  no  air  passed 
in  from  the  canula  or  syringe.     This  was  done 
on   the   11th   and   19th   of   October.       Her  last 
menstruation  occurred  on  the  6th  of  November, 
and  she  became  pregnant,  probably  on  the  19th 
of    October.     She    passed    her    pregnancy    fair- 
ly uneventfully,  and  labor  was  induced  on  July 
4th,  because  of  her  contracted  pelvis  and  mitral 
stenosis.     It  was  thought  at  this  time  that  the 
weight  of  the  baby  estimated  by  my  methods 
was  6  lbs.  5  oz.     She  was  delivered  the  same 
day,  after  a  short  labor,  of  a  normal  girl  child 
weighing  6  lbs.  4  oz. :   one  ounce  less  than  the 
estimated  weight. 

This  case  had  no  relations  with  her  partner 
other  than  the  two  mentioned  as  he  entered 
with  zest  into  the  scientific  experiment,  and 
believed  that  this  was  the  only  way  he  could 
have  a  child.  The  child  has  since  thrived  and 
grown  tremendously. 

Since  this  case  I  have  treated  four 
others,  all  unsuccessfully.  One  became 
pregnant  while  under  treatment.  She  mis- 
carried at  two  months.  This  case  is  not 
positive  as  she  acknowledged  relations  with 
her  husband  during  the  time  of  treatment 
and  outside  of  those  necessary  for  the 
treatments.  I  consider  this  case  very 
doubtful.  The  other  cases  were  all  cases 
of  infantile  genitalia. 

Doderlein  has  also  recently  reported  a 
case    of    successful    instrumental    fertiliza- 


tion. It  is  not  a  method  which  offers  very 
great  success,  and  should  not  be  used  save 
in  carefully  selected  cases.  Infection  must 
be  absolutely  excluded.  The  injections 
should  be  done  with  the  least*,  possible 
trauma.  The  solutions  should  be  mildly 
alkaline,  such  as  Locke's.  The  sperma- 
tozoa stand  heat  poorly  and  so  the  tem- 
perature should  never  be  above  ioo°  F. 
The  dilution  should  be  to  a  thin  consistency. 
They  seem  very  much  more  active  when 
there  is  considerable  dilution.  The  solu- 
tion should  always  first  be  examined  un^ 
der  the  microscope  to  ascertain  the  activity 
of  the  spermatozoa.  The  less  trauma  to 
the  uterus  from  instruments  the  more 
probability  of  success. 

It  is  not  a  treatment  which  commends 
to  the  esthetic  tastes,  but  will  occasionally 
give  a  good  result,  and  no  doubt  some 
harm  will  result  from  ill-chosen  cases. 

The  main  indication  in  the  treatment  of 
sterility  must  be  directed  toward  the  chief 
cause,  infantilism  of  the  genitalia,  par- 
ticularly of  the  uterus.  The  treatment, 
if  carefully  done,  should  involve  no  injury 
or  danger  to  the  woman.  Failure  leaves  her 
no  worse  for  her  experience ;  success 
brings  a  joy  to  the  parents  and  a  lasting 
visible  satisfaction  to  the  physician. 

There  is  no  more  pleasant  memory  in 
medicine  than  the  thought  of  such  victories. 

CHAPTER  XL 

THE   TREATMENT   OF   CYSTITIS   IN 
WOMEN,    WITH    REMARKS    ON 
THE  PRACTICAL  VALUE   OF 
THE   CYSTOSCOPE. 

The  modern  treatment  of  cystitis  is  the 
product  of  recent  years :  its  development  has 
depended  upon  improvement  in  the  struc- 
ture of  the  cystoscope  and  the  increase  in 

Page   Ten 


skill  and  knowledge  of  its  use.  At  the 
present  time  there  is  no  reason  why  every 
inflamed  bladder  in  women  should  not  be 
examined  cystoscopically  and  its  treatment 
intelligently  directed  and  controlled  by 
visual  inspection. 

The  passage  of  a  small  examining  cysto- 
scope  of  a  No.  14  size  (three-sixteenths  of 
an  inch  in  diameter)  is  not  a  matter  which 
causes  very  great  discomfort  or  disturbance. 
It  can  be  usually  slipped  in  without  the  pa- 
tient knowing  what  is  happening,  if  it  is 
well  lubricated,  and  examination  can  often 
be  made  by  the  retained  urine  alone  without 
water  dilatation.  Examination  through  the 
urine,  of  course,  does  not  give  as  good  re- 
sults as  does  water  dilatation ;  but  it  is  a 
useful  method  to  avoid  unnecessary  man- 
ipulation. Cocaine  or  anesthetic  solutions 
are  never  necessary  in  women.  I  have  not 
used  a  cocaine  solution  for  six  years. 

The  ease  of  insertion  of  the  modern  cysto- 
scope  makes  possible  direct  inspection  of 
the  site  of  inflammation  and  usual  knowl- 
edge of  the  effects  of  treatment :  in  this  way, 
it  is  possible  to  control  and  cure  affections 
of  the  bladder  in  a  direct  and  eflicient 
manner.  It  is  possible  to  make  an  exact 
diagnosis  of  the  bladder  lesion  and  appro- 
priate treatment  may  be  directed  toward  it. 

If,  however,  no  cystoscopic  examination 
is  made  in  cases  of  cystitis,  it  is  impossible 
to  localize  the  si1;e  of  inflammation,  acquire 
any  knowledge  of  its  size  and  location,  or 
eliminate  grave  and  dangerous  affections  of 
the  kidney  and  adjacent  organs.  Many 
bladder  and  kidney  lesions  may  produce 
mild  symptoms,  yet  be  of  such  momentous 
character  as  to  make  their  early  diagnosis 
a  necessity  for  the  welfare  of  the  patients. 

It  is  possible  with  the  cystoscope  to  de- 
tect the  presence  of  inflammation  by  the  ap- 
pearance of  the  bladder ;  ulcers  and  tumors 


of  the  bladder  wall  are  readily  seen  and 
treated;  the  source  of  blood  in  the  urine,, 
that  most  important  symptom  in  genito- 
urinary conditions,  may  be  definitely  located 
and  appropriately  treated.  An  intelUgent 
prognosis  cannot  be  reached  without  a 
definite  diagnosis  of  the  kidney  and  blad- 
der condition,  and  this  cannot  be  done  with- 
out visual  inspection  of  the  bladder  wall 
and  ureteral  orifices ;  it  is  often  necessary  in 
addition  to  catheterize  the  ureters  and  ob- 
tain urine  from  each  kidney  for  examina- 
tion. 

The  cause  and  progress  of  the  bladder 
disease  and  the  effect  of  treatment  upon  the 
condition  may  be  minutely  followed  by  the 
cystoscope.  Treatment  may  be  changed  to 
meet  conditions  that  may  arise  and  harm- 
ful procedures  may  be  eliminated.  There  is 
no  more  reason  why  the  female  bladder 
should  be  treated  without  a  cystoscope  than 
the  eye  without  an  ophthalmoscope,  or  the 
nose  and  throat  without  visual  inspection. 

Five  years  ago  I  published  the  records  of 
forty-five  cases^  of  cystitis  studied  cysto- 
scopically with  the  protocols  in  detail  and 
deductions  as  to  their  treatment.  This  re- 
port is  to  relate  further  experiences  with 
that  treatment  and  reference  only  to  par- 
ticularly interesting  cases  will  be  made  in 
order  to  avoid  elaboration  of  reports. 

Cystitis  is  a  very  common  disease  in 
women  and  is  very  frequently  overlooked. 
This  is  because  the  very  commonness  of  the 
disease  leads  women  to  believe  that  a  cer- 
tain amount  of  frequency  of  urination  is 
normal  and  usual.  This  can  be  easily 
proved  by  asking  every  one  of  your  woman 
patients  how  often  she  gets  up  at  night  to 
urinate.     A  woman  does  not  get  up  at  night 

'McDonald,  Ellice.  Cystitis  in  women  with 
report  of  forty-five  cases  studied  cj^stoscopically 
and  some  modifications  of  treatment.  Med. 
Rec.     1908.     Feb.  22. 


Page  Eleven 


to  urinate  unless  her  bladder  is  not  normal. 
Women  think  that  a  "cold  in  the  bladder" 
is  a  usual  occurrence  likely  to  happen  to  any 
person,  and  do  not  think  it  the  result  of  an 
inflammation  or  infection. 

The  study  of  the  disease  and  its  treatment 
is  impossible  without  an  understanding  of 
the  pathology  of  the  condition. 

The  most  common  condition  is  chronic  in- 
flammation of  the  trigone  or  trigonitis, 
which  results  usually  from  a  simple  hypere- 
mia and  congestion  of  the  vessels ;  actual 
infection  may  precede  or  follow  the  conges- 
tion. The  line  of  separation  between 
chronic  congestion  and  chronic  inflammation 
is  often  hard  to  determine.  There  is  usually 
hyperemia  with  marked  dilatation  of  the 
blood  vessels.  The  intimate  relations 
between  the  vesical  arteries  and  those  of 
the  neighboring  pelvic  organs  makes  this 
very  easy.  The  membrane  loses  its  lustre, 
the  mucosa  becomes  reddened  and  there  is 
evidence  of  flaky  desquamation  and  ex- 
foliation of  epithelial  cells,  leukocytes  and 
pus.  In  a  later  stage,  the  mucosa  of  the 
trigone  becomes  velvety  in  appearance  and, 
in  some  cases,  there  are  proliferating  proc- 
esses which  may  lead  to  papillary  or  papil- 
loma-like  excrescences. 

In  pregnancy,  this  picture  is  exaggerated, 
as  described  in  another  article,  with  a  con- 
siderable thickening  of  the  bladder  wall, 
increase  in  the  lymphatic  tissue,  hypertrophy 
of  the  muscle,  and  a  more  profuse  desqua- 
mation, of  epithelial  cells  and  pus.  Alto- 
gether the  bladder  wall  appears  softer  and 
thicker. 

The  tendency  toward  epithelial  prolifera- 
tion is  marked  in  the  acute  stages  of  cystitis, 
and  more  so  in  cystitis  of  pregnancy.  A 
change  from  the  normal  bladder  mucosa 
usually  occurs.  The  epithelium  is  thick- 
ened   and   papillary   projections    may    rise 


above  the  surface.  These  processes  may 
take  on  alveolar  arrangement  below  the 
surface. 

In  chronic  cystitis,  the  changes  are  more 
general :  the  mucous  membrane  has  lost  its 
normal  pinky  white  appearance  and  appears 
more  or  less  reddened.  This  reddening 
and  inflammation  may  appear  generally  or 
only  in  patches  as  when  the  inflammation 
extends  in  streaks  along  the  line  of  the 
blood  vessels  of  the  bladder  wall.  The 
mucosa  is  dull  red  in  color  and  here  and 
there  may  show  small  ulcerations.  There 
is  frequently  desquamation  of  the  epithelium 
and  interstitial  hemorrhages  showing  on  the 
surface  are  not  uncommon. 

Those  cases  of  chronic  cystitis,  which  are 
accompanied  by  disturbances  of  the  circula- 
tion or  enervation  of  the  bladder  such  as 
after  certain  operations,  are  often  resistant 
of  cure.  For  example,  in  fourteen  cases 
after  pelvic  operations  of  various  kinds,  the 
inflammation  was  very  difficult  to  cure. 
There  were  six  complete  hysterectomies, 
five  ventro-suspensions,  two  cystocele  opera- 
tions, one  perineorrhaphy,  and  one  oophorec- 
tomy. The  disturbance  of  anatomical  rela- 
tion in  these  cases  seemed  to  be  the  cause 
of  the  difficulty  of  cure.  It  is  interesting 
to  note  that,  after  supravaginal  hysterec- 
tomy, where  the  cervix  remains  as  a  support 
to  the  bladder,  there  does*  not  seem  to  be 
this  difficulty.  In  the  ventro-suspension, 
the  bladder  was  divided  into  two  cavities 
by  the  suspensory  Hgament  and  the  uterus. 
The  history  of  these  cases  has  been  tem- 
porary relief  or  cure  with  return  of  the 
bladder  symptoms  at  varying  intervals. 
The  abnormality  of  the  circulation  and 
nutrition  is  sufficient  to  make  the  bladder  a 
place  of  least  resistance  and  cause  a  re- 
crudescence of  symptoms. 


Page  Twelve 


Retroversion  also  causes  an  aggravation 
of  bladder  symptoms  and  makes  an  obstacle 
to  cure.  It  is  not  usually  sufficient  in  itself 
to  cause  bladder  irritation,  but  it  sometimes 
aggravates  it.  This  may  be  through  the 
the  fact  that  in  retroversion  there  is  some- 
times residual  urine :  so  that  the  bladder 
seldom  gets  thoroughly  drained,  or  it  may 
be  from  the  alteration  of  the  blood  supply 
or  enervation. 

The  muscle  of  the  bladder  is  sometimes 
involved  in  the  changes  of  cystitis  and  may 
hypertrophy  and  enlarge  to  project  into  the 
bladder  as  thick  bundles  or  network,  form- 
ing cavities  into  which  the  bladder  mucosa 
may  penetrate.  This  condition  is  usually 
associated  with  loss  of  bladder  tone.  This 
condition  is  suggestive  of  tabes,  and  was 
seen  in  three  cases  where  there  was  no  other 
evidence  of  syphilis.  They  were  benefited 
by  dilatation  of  the  orifice  and  by  faradiza- 
tion :  treatment  of  the  cystitis  was  done  at 
the  same  time. 

In  these  cases,  there  is  usually  a  certain 
rigidity  of  the  trigone,  particularly  of  the 
ureteral  orifices,  which  do  not  show  their 
usual  rhythmical,  sphincter-like  action  at 
each  exclusion  of  urine.  The  ridge  between 
the  two  orifices  is  usually  more  prominent. 
There  is  usually  residual  urine,  and  the  in- 
continence is  incontinence  of  retention. 

Stricture  of  the  urethra  is  another  lesion 
which  is  not  confined  to  the  male.  It  is 
usually  associated  with  a  sclerosing  vulvitis, 
which  sometimes  comes  in  age,  or  after  the 
premature  menopause.  It  has  been  seen 
four  times,  and  is  usually  associated  with 
dilatation  of  the  bladder  and  loss  of  tone 
with  dribbling  of  urine.  In  one  case  it  was 
so  small  as  to  hardly  allow  passage  of  a 
small  filiform.  Still,  dilatation,  first  with 
urethral  catheters  and  metal  probes  until  a 


small  glove-stretcher  dilator  could  be  in- 
serted, cured  all  of  them, 

A  direct  history  of  syphilis  was  given  in 
two  cases  which  had  incontinence  of  reten- 
tion and  loss  of  bladder  power  without  any 
trabeculae  or  noticeable  change  in  the  blad- 
der wall.  One  has  a  history  of  seventeen 
years  with  paralysis  of  the  hand.  She  im- 
proved under  faradization.  In  one  case 
there  appeared  to  be  a  syphilitic  ulceration 
about  the  size  of  a  dime  upon  the  fundus 
of  the  bladder.  There  was  some  false  mem- 
brane and  it  improved  under  mercury. 
Direct  treatment  did  not  seem  to  do  it  much 
good. 

Chronic  atrophic  cystitis  is  not  uncommon 
in  women  after  the  menopause,  and  it  is 
usually  associated  with  more  or  less  sclerosis 
and  atrophy  of  the  vulvar  parts.  The 
mucosa  in  atrophic  cystitis  is  dull  and  thick- 
ened. The  blood  vessels  are  not  seen  at  the 
fundus  and  there  is  often  atrophic  retrac- 
tion of  the  ureteral  orifices.  This  process 
is  usually  accompanied  by  more  or  less  irri- 
tating hypertrophic  trigonitis.  This  condi- 
tion is  the  most  common  cause  of  frequency 
of  urination  in  women  past  the  menopause 
and  is  not  easy  to  cure. 

Inflammation  of  the  bladder  is  usually 
affected  by  congestion  of  adjacent  organs. 
Thus  an  endocervicitis  with  enlargement  of 
the  cervix  is  a  not  infrequent  accompani- 
ment of  a  congestive  hypertropic  trigonitis. 
The  intimate  relations  of  the  cervix  and 
trigone  explain  this  association.  The  en- 
larged cervix  also  often  presses  upon  the 
trigone  which  from  the  existing  inflamma- 
tion has  lost  its  normal  elasticity  and  this 
will  often  cause  alteration  in  the  structure 
and  appearance  of  the  ureteral  orifices,  so 
that  from  being  small  elevated  papillae, 
they  become  stretched,  flattened  and  elon- 


Page  Thirteen 


gated.     A   similar   condition   is    sometimes 
caused  by  the  enlarged  cervix  of  pregnancy. 

Tuberculous  cystitis  can  be  readily  recog- 
nized cystoscopically  if  the  little  gray  white 
tubercles  can  be  seen :  but  after  they  have 
broken  down  and  become  ulcerated,  it  is 
more  difficult  to  diagnose  this  condition 
cystoscopically.  In  the  study  of  sedimented 
urine  for  tubercle  bacilli,  Ellerman  and  Er-  ■ 
landsen's  method  of  sputum  examination  is 
of  distinct  value.  This  consists  of  the  ad- 
dition of  half  a  volume  of  0.6  per  cent. 
sodium  carbonate  to  the  sediment  and  diges- 
tion for  twenty-four  hours.  The  super- 
natant fluid  is  poured  off  and  four  volumes 
of  0.25  per  cent,  sodium  hydroxide  is  added. 
After  careful  agitating,  it  is  brought  to  boil- 
ing point — then  centrifugated  again.  This 
increases  the  chance  of  finding  the  tubercle 
bacilli  many  times.  Centrifugation  must  be 
long  and  rapid. 

No  results  were  obtained  with  Rovsing's 
5  per  cent,  carbolic  acid  irrigations  in  tuber- 
culous cystitis  except  a  great  deal  of  bladder 
pain. 

The  appearance  of  ulceration  around  the 
orifice  of  a  ureter  is  always  suggestive  of 
infection  of  the  kidney  upon  that  side.  This 
is  true  of  chronic  kidney  infections,  such  as 
tuberculosis  of  the  kidney  where  there  has 
been  irritation  of  that  orifice  for  a  long 
time. 

The  treatment  of  these  cases  of  cystitis 
has  consisted  of  irrigations  of  a  bland 
cleansing  fluid.  This  solution  usually  con- 
sisted of  sodium  bicarbonate,  one  dram  to 
the  quart.  This  is  a  better  solvent  of 
mucus,  pus,  and  albuminous  substances 
generally  than  is  the  boric  acid  solution  so 
commonly  used.  This  is  well  known  by 
otologists,  who  recognized  the  value  of  al- 
kaline solutions  in  suppurative  ear  diseases. 
If  there  was  a  great  deal  of  mucus,  the  solu- 


tion was  made  of  double  strength,  and,  if 
there  was  a  great  deal  of  pus,  one  dram  of 
sodium  sulphate  was  added  to  the  cleansing 
solution.  These  mixtures  are  bland  and 
cleansing,  and  offer  some  advantage  over 
the  common  boric  acid  solution. 

Various  antiseptic  solutions  were  tried  in 
the  hope  of  finding  one  which  would  give 
the  maximum  of  effect  with  the  minimum 
of  disturbance.  It  should  be  remembered 
in  the  treatment  of  cystitis  that  it  is  only  in 
the  stage  of  purulent  cystitis  that  germi- 
cides are  of  value.  The  infective  organism 
which  started  the  process  has  little  action 
in  keeping  up  the  tissue  changes.  The  deep 
infiltrations  and  cell  changes  continue  with 
the  chronic  irritation  of  the  ever  present 
urine. 

The  best  results  were  obtained  with 
quinine  bisulphate  from  1-3000  to  i-iooo. 
This  is  a  germicide  of  great  value  and  is 
comparatively  unirritating.  It  was  used 
constantly  as  a  medium  for  bladder  dilata- 
tion in  ureteral  catheterization.  It  should 
be  begun  in  the  weaker  strength.  Anti- 
pyrin  i-ioo  is  another  useful  irrigation  in 
chronic  trigonitis. 

Various  silver  salts  have  been  tried.  The 
various  colloidal  silver  salts  were  not  used 
as  Derby  found  that  of  these  preparations 
argyrol  and  collargol  are  inert  as  bacteri- 
cides and  that  all  the  colloid  silver  salts  are 
inefficient  in  the  presence  of  albuminous 
matter.  The  preparations  may  be  divided 
into  two  classes :  the  non-irritating  of  low 
bactericidal  power  as  argyrol  and  collargol 
and  the  more  effective  and  slightly  irritat- 
ing bactericides  as  protargal.^  Protargol 
5%  was  used  sometimes. 

However,  it  was  found  that  silver  nitrate 
was   the   most   efficient   and   that   the   less 


^Derby,  Boston.     Med.  and  Surg.  Jour.,  1906, 
Sept.   27. 


Page  Fourteen 


amount  of  irritation  from  the  newer  silver 
salts  depended  upon  their  weakness  and 
slow  action.  Silver  nitrate  gives  as  good 
results  if  the  solution  is  fresh  and  weak 
(0.5  per  cent.)  and  the  viscosity  of  the  solu- 
tion is  increased  in  order  to  obtain  slowness 
of  action.  This  may  be  done  by  adding- 
glycerine  20%  or  other  substances  which 
do  not  neutralize  the  silver  nitrate. 

In  acute  purulent  cystitis  with  exfoliation 
and  pus  formation,  the  colloid  silver  salts 
were  used  with  hydrogen  peroxide  as  a 
cleaning  and  antiseptic  combination.  It  has 
been  shown  that  in  the  treatment  of  necrotic 
endometritis  and  suppurating  wounds,  if  a 
colloid  silver  compound  is  used  along  with 
hydrogen  peroxide,  the  action  of  each  is 
made  much  more  effective.  For  this  reason 
the  two  were  combined  in  the  treatment  of 
purulent  cystitis.  Hydrogen  peroxide,  one- 
third  strength,  and  protargol,  5  per  cent., 
were  injected  alternately  through  a  catheter 
into  the  bladder  by  means  of  a  half-ounce 
syringe.  The  mixture  was  allowed  to  act 
for  a  few  minutes,  then  it  was  washed  out 
by  the  cleansing  solution,  injected  by  the 
same  syringe.  No  difficulty  or  trouble  was 
ever  noted  from  distention  of  the  bladder 
by  the  peroxide.  The  peroxide  foam  poured 
out  of  the  catheter  and  was  finally  washed 
out  by  the  quinine  solution  or  the  cleansing 
solution.  This  treatment  is  not  one  which 
would  be  advised  for  cystitis  in  the  male, 
but  it  has  given  excellent  results  in  purulent 
cystitis  in  the  female. 

The  exfoliation,  desquamation,  and  pus 
cells  are  in  this  way  washed  away,  as  they 
cannot  be  by  any  irrigation;  the  bladder 
mucous  membrane  is  left  clean,  and  is  pre- 
pared for  treatment  by  antiseptic  or  astrin- 
gent solutions  or  for  direct  applications. 

For  direct  applications  to  ulcers  and  local- 


ized inflamed  spots,  nitrate  of  silver  fused 
on  a  metal  probe,  or  protargol  solution  on  a 
swab,  was  used.  The  patient  was  put  in 
the  knee-chest  position,  and  applications 
were  made  through  the  Garceau  cystoscope. 
The  place  for  the  application  was  first 
located  by  means  of  the  examining  cysto- 
scope under  water  dilatation.  If  an  ap- 
plication of  a  solution  is  required,  it  will  be 
found  useful  to  dip  the  end  of  the  probe 
into  collodion  in  order  to  make  the  cotton 
stick  closely. 

It  was  also  found  that  in  cases  of  acute 
cystitis,  or  cases  where  there  had  been  ex- 
tensive treatment,  a  soothing  application 
was  of  benefit.  Olive  oil  was  used  with 
some  success,  but  finally  a  preparation  of 
Irish  moss  was  found  to  be  the  most  useful. 
The  value  of  this  preparation  consists  in 
keeping  the  bladder  walls  apart  and  lubricat- 
ing them,  so  that  no  friction  or  irritation 
results.  The  preparation  is  approximately 
the  same  as  many  lubricating  jellies  put  up 
in  tubes  for  use  in  vaginal  examination. 
This  soothing  lubricating  preparation  of 
Irish  moss  is  also  of  use  in  lubricating  the 
cystoscope  before  its  introduction  into  the 
urethra.     It  is  prepared  as  follows : 

Chondrus    (Irish  moss)        45  g. 
Distilled   water    1500  c.   c. 

Wasli  the  Irish  moss  in  cold  water,  drain  off 
water;  wash  again  and  drain.  To  the  washed 
Irish  moss  add  1,500  c.  c.  of  distilled  water 
and  boil  for  ten  or  fifteen  minutes,  stirring 
frequently.  Strain  through  muslin  with  ex- 
pression. To  the  strained  Irish  moss  add 
4,500  c.  c.  of  boiling  distilled  water  and  filter. 
The  process  of  filtration  may  be  hastened  by 
loosely  filling  the  filter  with  absorbent  cotton. 
Evaporate  the  filtrate  to  one-fifth  by  bulk, 
cool  partially  and  add  gomonal,  1  per  cent,  by 
weight,  mix  well  and  strain  through  fine  white 
flannel  which  has  been  previously  boiled.  Bot- 
tle in  ground  glass  stoppered  containers  of 
about  half  a  pint  each. 

This  Irish  moss  jelly  makes  a  useful 
lubricant  for  examinations  and  may  be  put 


Page  Fifteen 


up  in  sterilized  metal  paint  tubes  for  that 
purpose.  In  bladder  treatment  the  jelly 
should  be  diluted  with  hot  water  to  a  thick 
semisolid  consistency,  fit  for  use  in  a 
syringe. 

The  treatment  of  these  cases  of  cystitis 
consisted  mainly  in  the  use  of  four  com- 
pounds :  the  antiseptic  quinine  solution,  the 
cleansing-  bicarbonate  solution,  the  peroxide 
and  silver  combination,  and  the  jelly  of 
Irish  moss.  In  addition  to  this,  appropriate 
treatment  was  directed  to  ulcers  by  direct 
application  of  silver  or  curettage,  as  was 
required ;  chronic  patches  of  inflammation 
were  stimulated,  and  lesions  in  the  neigh- 
boring organs  were  treated. 

If  the  case  was  one  of  acute  purulent 
bladder  disease,  the  bladder  was  first  in- 
spected and  a  diagnosis  made,  the  bicarbon- 
ate solution  being  used  as  the  dilating  fluid. 
The  pus  and  shreds  were  then  washed  away 
by  the  peroxide  and  silver  combination. 
The  bladder  was  then  washed  and  dilated 
by  the  quinine  solution  and  more  exact  ex- 
amination made  for  small  ulcers,  patches  of 
inflammation,  and  the  condition  of  the 
ureteral  orifices.  If  it  were  necessary  to 
catheterize  the  uterus,  it  was  usually  done 
under  the  quinine  solution  and  after  the 
bladder  had  been  cleansed.  It  was  believed 
that  in  this  way  danger  of  carrying  infec- 
tion upwards  from  the  bladder  was  elim- 
inated, the  cleansed  bladder  wall  and  anti- 
septic quinine  solution  removing  this  small 
danger.  The  quinine  solution  gives  a 
peculiar  bluish  appearance  through  the 
cystoscope,  but  examinations  can  be  well 
made  with  it. 

If  the  case  is  one  of  very  acute  irritation, 
the  Irish  moss  jelly  is  injected  on  removal 
of  the  quinine  solution.  The  amount  of 
jelly  injected  should  vary  from  one  to  four 


ounces.  If,  however,  the  bladder  inflam- 
mation is  more  chronic,  the  patient  is  told 
to  retain  the  quinine  solution  as  long  as  pos- 
sible in  order  to  get  full  benefit  from  its  an- 
tiseptic and  astringent  action.     ^^ 

In  chronic  cases  with  much  congestion 
and  irritation  the  peroxide  and  silver  com- 
bination was  seldom  used.  The  aim  of 
the  treatment  in  all  cases  was  first  to  cleanse 
the  infected  area,  to  direct  appropriate 
treatment  toward  the  special  lesion,  and  to 
exercise  an  antiseptic  astringent  and 
stimulating  action  upon  the  mucous  mem- 
branes by  means  of  the  quinine  solution. 

It  was  also  found  useful  to  use  various 
drugs  by  the  mouth.  Infusion  of  buchu 
and  fluid  extract  of  triticum  are  old  favorites 
and  have  no  equals  for  making  the  urine 
bland  and  unirritating.  Tincture  of  bella- 
donna, or  hyoscyamus  and  potassium  citrate 
or  sodium  bicarbonate  should  be  used  in 
combination  to  relieve  spasm  and  make  the 
urine  alkaline.  It  is  required  in  cases  of 
cystitis  that  the  urine  be  made  alkaline  dur- 
ing the  irritating  stage  of  the  disease.  Acid 
urine  is  always  irritating.  The  patient 
should  also  be  directed  to  drink  large  quan- 
tities of  water  and  a  specified  amount  of 
six  glasses  should  be  named  in  order  that 
the  directions  be  carried  out.  Aspirin  is 
a  drug  which  is  sometimes  of  use  to  relieve 
irritation ;  when  hexamethylentetramin  is 
used ,  it  should  be  combined  with  an  equal 
amount  of  sodium  benzoate  to  relieve  the 
kidney  irritation  which  it  may  cause. 

As  the  bladder  is  getting  better,  great 
gentleness  should  be  used  in  treatment  and 
in  catheterization  of  the  urethra  as  described 
in  another  article  upon  the  prevention  of 
catheter  cystitis.  Otherwise  the  patient 
may  recover  from  her  cystitis  and  have  still 


Page  Sixteen 


to  recover  from  the  treatment.  The  mjury 
caused  by  the  passage  of  a  catheter  may  in- 
duce a  urethritis.  The  last  few  treatments 
should  be  of  a  bland  solution. 

These  methods  have  been  in  use  for  nine 
years  in  my  hands  and,  in  spite  of  the  ex- 
perimental trial  of  scores  of  other  astrin- 
gents and  germicides,  the  cheap  efficient 
substances  have  given  me  good  results. 


CHAPTER  III. 

THE  TREATMENT  OF  LEUOORRHEA 

DUE   TO   GONOCOCCUS  INFEC. 

TION. 

General  Considerations. — Leucorrhea, 
wnite  or  purulent  discharge,  is  one  of  the 
commonest  symptoms  of  gonococcus  infec- 
tion and  its  treatment  is  essentially  the  treat- 
ment of  that  infection,  except  in  salpingitis. 
Not  every  case  of  leucorrhea  by  any  manner 
of  means  is  due  to  this  infection,  but  leucor- 
rhea is  almost  constantly  found  in  gono- 
coccus infection  of  the  cervix  and  vulva. 

The  great  prevalence  of  this  form  of  dis- 
ease in  men  and  women  makes  its  con- 
sideration of  greatest  social  and  economical 
importance.  The  frequency  of  its  occur- 
rence in  the  community  there  is  no  means 
of  knowing;  Zweifel  and  Sanger  claimed 
that  about  i8  per  cent,  of  all  women  have 
gonorrhea.^  This  may  be  excessive,  but  in 
any  case  it  is  suggestive  of  the  fearful 
prevalence  of  the  disease. 

It  was  formerly  taught  that  this  infection 
in  women  was  practically  incurable.  One 
professor  of  gynecology  has  stated  that  it 
were  better  that  a  millstone  be  tied 
around  her  neck  and  she  be  cast  into  the 

^Sanger:  Verhand.'  d.  deutsch.  Gesellsch., 
1886.  I,  177. 


sea  than  that  a  woman  should  have  gonor- 
rheal infection.  This  pessimistic  belief 
and  teaching  is  responsible  for  the  lack  of 
treatment  and  investigation  of  the  disease, 
and  it  is  misleading  and  untrue.  Gonococ- 
cus infection  not  only  can  be  cured,  but  often 
is  cured  before  it  advances  to  salpingitis, 
and  while  the  disease  is  still  confined  to  the 
cervix  and  vulva.  This  is  the  stage  in 
which  local  medical  treatment  should  be 
applied  and  the  stage  in  which  the  chances 
of  cure  are  greatest. 

Pathology.—  To  properly  administer 
the  treatment,  the  course  and  pathology  of 
the  disease  should  be  understood.  The  dis- 
ease is  usually  thought  to  be  an  endome- 
tritis, but  there  is  usually  no  infection  of 
the  interior  of  the  uterus  save  in  the  early 
acute  stages,  in  the  puerperium,  or  some- 
times after  menstruation  in  the  early  stages 
of  the  disease.  The  distribution  of  the  in- 
fection, extending  as  it  does  by  means  of 
the  continuity  of  the  mucosa,  is  dependent 
upon  the  character  and  kind  of  mucous 
membrane.  It  readily  attacks  and  thrives 
in  glandular  structures  and  unstratified 
epithelium.  For  this  reason  the  common 
sites  of  inflammation  are  Skene's  glands 
in  the  urethra,  the  vulvo-vaginal  glands 
and  the  glands  of  the  cervix.  The  walls  of 
the  vagina  and  the  uterus  are  not  usually 
involved,  although  they  may  be  in  the  acute 
stages  or  when  their  tissue  is  changed  or 
softened,  as  in  the  puerperium.  The  dis- 
charge which  apparently  comes  from  the 
uterus,  is  really  cervical  and  originates  from 
the  interior  of  the  cervix  below  the  internal 
OS.  The  cervical  glands  are  present  two- 
thirds  or  more  of  the  way  up  the  cervical 
canal. 

The  usual  point  of  greatest  involvement 
is  in  the  duct  of  the  glands.     The  inflamma- 


Page  Seventeen 


tion  here  blocks  up  the  outlet  of  the  gland 
with  the  result  that  often  small  cystic  collec- 
tions accumulate.  If  the  gland  is  not 
blocked,  there  is  a  purulent  discharge  from 
it.  This  discharge  usually  becomes  worse 
after  the  cessation  of  the  menstruation, 
when  there  is  usually  a  slight  exacerbation 
of  the  disease.  The  cervix  becomes  en- 
larged, often  nodular  from  cystic  collec- 
tions and  indurated.  This  is  due  to  the 
products  of  inflammatory  disease  and  prin- 
cipally plasma  cells  and  lymphocytes.  The 
presence  of  an  exceptionally  large  number 
of  plasma  cells  macroscopically  is  almost 
characteristic  of  gonorrheal  cervical  infec- 
tion. The  exudate  contains  a  large  number 
of  polymorphonuclear  leukocytes,  which 
are  present  immediately  below  the  epithe- 
lium. There  are  also  seen  numbers  of 
deeply  staining  basophilic  granular  irregular 
minute  bodies,  the  so-called  Fleming's 
bodies.  There  are  also  sometimes  seen  in 
the  submucosa  a  few  hyaline  pink-staining 
bodies  varying  in  size  from  one  to  six  times 
the  diameter  of  a  plasma  cell.  The  micro- 
scopic appearance  of  the  tissue  suggests 
that  the  lesions  are  the  result  of  periodical 
exacerbations  and  remissions  of  the  inflam- 
mation which  has  spread  and  lights  up 
again  and  again  from  the  mucous  surface. 

Diagnosis. —  The  diagnosis  is  often  very 
difficult.  The  history  of  an  attack  of  fre- 
quency of  urination  and  discharge  is  of 
most  value.  This  discharge  is  usually 
worse  after  a  menstrual  period.  Inflam- 
mation of  the  trigone  of  the  bladder  is 
common.  The  inflammation  may  be  noted 
in  the  red  orifices  of  the  vulvo-vaginal 
glands,  sometimes  in  the  urethral  glands 
and  in  the  thickened  inflamed  indurated 
cervix.  If  examination  takes  place  soon 
after  a  menstruation,  the  reddened  spots 
are  more  easily  seen. 


The  microscopic  examination  of  the  dis- 
charge offers  some  evidence.  There  are 
usually  in  simple  leucorrhea,  numerous 
flat  epithehal  cells,  which  stain  well  with 
disintegrated  cellules  with  proliferating 
nuclei  and  lymphocytes  with  numerous 
cocci,  Doderlein's  or  other  bacteria.  In 
gonococcus  infection,  on  the  contrary,  there 
are  few  flat  normal  vaginal  cells,  many  dis- 
integrated or  degenerating  epithelial  cells, 
numerous  polymorphonuclear  leukocytes 
with  often  the  characteristic  biscuit-shaped 
organisms  often  intracellular.  The  appear- 
ance of  the  organism  must  be  very  charac- 
teristic, before  the  diagnosis  can  be  made, 
as  the  vagina  often  harbors  cocci  both  Gram- 
positive  and  Gram-negative,  which  are  very 
like  the  gonococcus.  The  gonococcus  is 
also  often  absent  in  the  first  stages  of  the 
infection. 

The  exact  diagnosis  of  the  disease  must 
depend  upon  cultural  methods,  although  it 
is  usually  easy  to  reach  a  presumptive  diag- 
nosis without  them.  Cultures  taken  from 
the  cervical  discharge  usually  give  poor 
results,  as  the  microorganisms  are  often 
dead.  Sometimes  during  an  exacerbation, 
as  after  menstruation,  a  growth  may  be 
got  from  the  discharge,  but  better  results 
are  obtained  from  swabs  taken  by  rubbing 
the  sterile  cotton  on  a  stick  like  diphtheria 
tubes  directly  over  the  infected  mucous 
surface.  In  this  way,  organisms  are  ob- 
tained directly  from  the  tissues  where  they 
grow.  This  should  be  done,  if  possible, 
about  two  days  after  menstruation  ceases. 
The  culture  media  should  be  hemoglobin 
agar,  such  as  described  in  my  article  upon 
puerperal  gonococcus  infection. 

Course  and  Prognosis. — The  chronic 
course  of  the  disease  is  due  to  certain  in- 
fluences which  affect  it  adversely.  The 
factors  which  excite  the  disease  and  cause 


Page  Eighteen 


its  extension  and  continuance  are  (ij  re- 
peated fresh  infections,  (2)  coitus,  (3) 
menstruation,  (4)  pregnancy,  (5)  sharp 
curettage  and  (6)  tamponage.  When  it  is 
considered  how  often  all  these  occur,  it  is 
no  wonder  the  disease  is  considered  diffi- 
cuh  to  cure. 

The  repeated  fresh  infections,  if  from  the 
husband,  are  usually  explained  by  fresh  or 
chronic  old  infection;  although  Erb  thinks 
that  our  estimates  of  this  have  been  exag- 
gerated and  that,  of  2,400  male  patients, 
who  had  had  gonorrhea,  only  4.5  per  cent, 
infected  their  wives. ^  But  in  any  case,  this 
should  be  considered. 

Treatment. —  Menstruation,  pregnancy, 
and  coitus,  all  do  harm  from  the  addition 
of  congestion  and  distribution  of  the  infec- 
tion. During  menstruation  and  for  three 
days  after,  the  patient  should  remain  very 
quiet  and  take  all  the  rest  possible,  in  order 
to  limit  the  extension  of  the  disease.  After 
pregnancy,  the  tendency  is  for  the  disease 
to  extend,  as  is  described  in  the  article  on 
puerperal  gonococcus  infection.  Coitus 
should  be  restricted  during  the  acute  stages 
and  not  allowed  until  the  cervix  appears 
normal. 

Sharp  curettage  of  the  uterus  does  harm, 
because  it  bares  a  raw  surface  which  is  not 
infected  and  causes  infection  in  an  area  not 
previously  involved.  The  gonococcus  can 
find  no  permanent  hold  in  the  uterine  mu- 
cosa, provided  it  is  not  injured,  but  after 
curettage  or  after  pregnancy,  the  raw  sur- 
face and  exudation,  as  a  result  of  the  in- 
flammation caused  by  the  trauma,  offer  a 
fine  nidus  and  a  good  culture  medium  for 
the  extension  of  the  gonococcus.  It  is  true 
that  the  endometrium  usually  recovers,  but 

'Erb:     Munch,     med.     Wochens.,     1906,     27. 
Munch,  med.  Wochens.,  1907,  31. 


in  the  meantime  an  opportunity  has  been 
given  for  extension  of  the  disease  to  the 
Fallopian  tubes  with  its  attendant  dangers 
and  discomforts.  This  upward  tendency 
also  exists  after  pregnancy.  Why  sharp 
curettage  should  ever  be  advised  in  this  dis- 
ease or  for  leucorrhea  is  impossible  to  ex- 
plain. It  injures  the  only  uninvolved  part 
and  does  no  good  but  actual  harm.  It  is  like 
shooting  the  innocent  bystander  in  a  street 
brawl.  An  example  of  this  is  a  report  of 
six  cases,  reported  by  Holden,^  which  were 
curetted  and  the  pelvic  organs  noted  as  "ap- 
parently normal,"  but  returned  some  time 
afterwards  and  had  their  Fallopian  tubes 
excised  for  purulent  salpingitis. 

But  the  whole  treatment  of  the  disease 
has  been  based  upon  empiricism  and  a  false 
idea  of  the  pathological  anatomy.  Another 
hoary  myth  is  the  belief  that  the  introduc- 
tion of  tampons  does  good.  Why  should 
they?  The  essential  points  in  the  treat- 
ment of  the  condition  must  be  lack  of  con- 
gestion and  irritation,  rest  and  free  drain- 
age, with  proper  germicidal  measures.  The 
tampon  is  an  irritative  foreign  body  which 
obstructs  drainage  and  macerates  the  mu- 
cosa, so  that  extension  of  the  infection  is 
more  likely  and  occlusion  of  the  ducts  of 
the  glands  more  easy.  If  any  antiseptic  is 
introduced  with  it,  the  continued  application 
is  irritating,  as  for  example,  ichthyol-gly- 
cerine  tampons  with  which  almost  every 
one  has  had  the  experience  of  getting  a  fine 
cast  of  the  vagina.  It  has  the  effect  of  a 
moist  glycerine  dressing.  Let  any  one  ex- 
periment with  a  moist  glycerine  dressing 
upon  one  of  "his  own  mucous  surfaces  and 
he  will  find  what  irritation  and  maceration 
it  produces.  So  influenced  was  I  by  custom 
and  previous  practice    that    I    introduced 

^Holden:     American  Medicine,  1905,  Nov.   4. 


Page  Nineteen 


several  thousand  tampons  before  I  was 
convinced  of  their  harm  and  uselessness. 
Such  is  the  influence  of  tradition.  I  tam- 
poned with  all  mixtures  and  shades  and  per- 
centages of  glycerine,  ichthyol,  boric  acid, 
chloral  and  such.  I  tamponed  one  woman 
with  gonococcus  infection  twice  a  week  for 
two  years,  at  the  end  of  which  time  she  was 
worse  than  in  the  beginning,  and  the  dis- 
ease had  extended  to  the  tubes.  But  it  had 
a  great  psychic  influence — but  none  on  the 
disease.  The  facts  are  that  nobody  ac- 
tually knows  what  good  tampons  do,  save 
in  prolapse  or  retroversion ;  but  it  is  some- 
thing to  do,  and  many  things  are  done, 
because  it  makes  the  physician  and  patient 
feel  something  is  being  done  for  the  dis- 
ease. It  will  go  the  way  of  intrauterine  ap- 
plications to  oblivion. 

The  essentials  in  the  treatment  are  free 
drainage  and  germicidal  applications  and 
douches.  The  infection  lurks  in  the  glands 
of  the  cervix  and  upon  the  mucosa.  The 
indication  is  to  drain  the  obstructed  glands 
and  apply  real  germicides  to  the  mucosa. 

The  drainage  of  the  obstructed  glands  is 
best  obtained  by  the  electric  thermocautery. 
A  small  narrow  wire  loop  point  should  be 
used  about  the  breadth  of  the  lead  of  an 
ordinary  pencil.  The  cauterization  is  best 
done  in  the  middle  of  the  menstrual  month 
and  should  be  preceded  by  germicidal 
douches.  With  a  bivalve  speculum  expos- 
ing the  cervix,  the  small  cautery  at  a  red 
heat  is  thrust  into  each  eminence  and  cystic 
collection  in  the  indurated  and  inflamed 
cervix.  It  is  also  thrust  about  ys,  inch 
into  places  in  the  cervix  where  it  seems 
most  indurated  and  inflamed.  In  all,  about 
IO-20  punctures  with  the  cautery  may  be 
done  at  one  sitting.  A  month  should  elapse 
between     cauterizations.       This     treatment 


opens  the  glands  and  destroys  collections 
and  relieves  congestion,  so  that  the  cervical 
circulation  may  take  care  of  the  infection. 
It  seldom  needs  to  be  done  more  tfean  three 
times,  unless  there  is  continued  reinfection. 
The  patient  should  keep  quiet  after  the 
treatment  for  two  days  and  should  be 
warned  that  the  discharge  is  apt  to  increase 
at  first.  This  treatment  is  not  needed  more 
than  once  in  most  cases.  It  is  not  painful, 
it  does  no  harm  and  may  even  be  done  in 
the  presence  of  salpingitis.  It  is,  however, 
most  applicable  to  the  chronic  or  subacute 
stages  of  the  disease.  In  the  acute  stages, 
rest  and  proper  douching  are  the  chief  in- 
dications. 

In  addition  to  this  treatment,  applications 
of  germicides  are  made  to  the  cervix  and 
the  infected  glands  of  the  vulva  and  urethra. 
The  cervix  is  swabbed  and  the  glands  of 
the  vulva  are  probed.  Several  germicides 
may  be  used. 

Tincture  of  iodine  is  an  old  favorite. 
This  has  a  Rideal- Walker  carbolic  acid  co- 
efficient of  2,  that  is,  it  is  twice  as  germicidal 
as  pure  carbolic  acid.  Chlor-meta-kresol  is 
a  halogen  compound  which  makes  a  useful 
applicant.  This,  in  the  50  per  cent,  oily 
solution,  has  a  Rideal- Walker  carbolic  acid 
coefficient  of  11.5.  It  is  a  useful  applica- 
tion and  causes  little  pain.  The  oily  solu- 
tion has  an  advantage  of  continued  slow 
action. 

This  substance  is  also  useful  to  give  in 
douches  in  i-iooo  of  the  oily  fifty  per  cent, 
solution.  It  can  be  afterwards  increased 
to  1-500.  Occasionally  it  causes  tingling, 
but  is  non-toxic  and  only  slightly  affected 
by  albuminous  fluids  and  is  perfectly  harm- 
less to  the  mucosa.  Its  high  germicidal 
action  makes  it  of  use.  After  the  discharge 
besfins  to  lessen  and  all  the  cauterizations 


Page  Tiventp 


have  healed,  it  is  best  to  nse  a  plain  alkaline 
douche  of  soda  bicarb,  .^/i,  sod.  sulphat.  oii 
to  2  quarts  of  warm  water. 

The  use  of  bichloride  of  mercury  and 
formalin  douches  are  illogical  in  this  condi- 
tion. Bichloride  in  the  presence  of  organic 
tissue,  such  as  mucosa,  or  albuminous  dis- 
charges, become  inert.  The  leucorrheal 
discharge  neutralizes  it,  so  that  the  action 
of  the  douche  is  only  mechanical  and  not 
germicidal — another  illusion  of  which  the 
treatment  of  this  disease  has  been  made  up. 

Precautions  should  be  taken  in  regard  to 
rest  at  the  menstruation,  care  of  the  bowels 
and  general  health,  prevention  of  reinfec- 
tion, etc.  But  the  active  treatment  of  the 
disease  should  be  confined  to  the  cautery, 
douches  of  real  germicidal  value  and  occa- 
sional local  applications  of  a  germicide.  In 
this  way,  rest,  drainage  and  cleanliness 
are  obtained,  and  the  disease  may  be  cured 
and  the  extension  to  the  Fallopian  tubes 
prevented.  It  is  only  our  inefficient  and 
illogical  methods  which  have  made  this  dis- 
ease appear  hard  to  cure. 

CHAPTER   IV. 

THE    TREATMENT    OF   FIBROID   TU- 
MORS, WITH  REPORT   OF  700 
CASES. 

The  study  of  uterine  fibroids  has  a  di- 
rect bearing  upon  their  treatment.  If  these 
growths  cause  no  more  trouble  than  uterine 
hemorrhage,  their  treatment  may  be  de- 
cided u,pon  after  consideration  of  how  severe 
is  the  hemorrhage :  but  if  there  are  other 
dangers,  then  the  treatment  must  be  chosen 
after  consideration  not  only  of  the  pres- 
ent symptoms,  but  also  of  the  probable 
changes  which  may  occur  in  the  tumor  and 
their  danger  to  life. 


With  the  hope  of  being  able  to  obtain 
some  idea  of  the  degenerations  and  the 
relation  of  malignant  changes,  700  tumors 
were  studied.  In  any  such  series  it  is 
of  importance  that  it  should  be  carefully 
done  and  all  tumors  should  be  examined 
microscopically.  It  has  been  thought  best 
not  to  combine  with  this  series  any  others 
as  a  single  series  of  such  numbers  is  of 
more  value  than  an  aggregation  of  cases 
unevenly  prepared  and  collected  from 
many  operators.  The  cases  have  been 
studied  from  the  point  of  view  of  age  and 
its  relation  to  cancerous  changes  and  de- 
generations and  the  tables  tell  their  own 
tale. 

TABULAR     ANALYSIS      OF      AGE,     COMPLICA- 
TIONS     AND      DEGENERATIONS      OF      700 
FIBROID    TUMORS. 

TABLE     1.      CHARACTER    OF     TU3IORS. 

No.  % 

Single    238  34 

Multiple    462  66 

Small,  up  to  4  c.  m 257  36.7 

Medium,  4-8  c.  m 209  29.8 

Large,  above  8  c.  m 234  33.5 

Subserous    136  19.5 

Interstitial     190  27.1 

Submucous    75  10.7 

Combined    299  42.7 

TABLE     2.  DEGENERATIONS     AND     3IALIG- 

NANT    CHANGES. 

(A.)     Degenerations  of  Tumor. 

No.  % 

Hyaline    127  18 

Calcareous     65  9 

Cystic    20  3 

Hemorrhagic    14  2 

Necrotic     57  8 

Adenomyoma    23  3 

(B.)     Associated  Malignant  Changes. 

No.  % 

Adenocarcinoma    20  2.9 

Squamous    carcinoma    6  0.8 

Sarcoma     7  1 

Chorioepithelioma  malignum   . .     2  0.3 

Total   malignant   changes    35  5 

TABLE     3.      COMPLICATIONS     OF     TUMORS. 

No.  % 

Ovarian   cysts    53  7.5 

Cystic  ovaries    141  20 

Ovarian  fibroma   8 

Ovarian    carcinoma    5 

Salpingitis     .- 194  27.5 

Appendicitis  or  Periappendicitis  148  21 


Page  Twenty-one 


TABLE    4.      AGE    OF    PATIENT. 

Age 

No.         %                       Age         No. 

% 

20-30 

19           2.7                     50-60         95 

13 

30-40 

233         33                       60-70         21 

3 

40-50 

332 

TABLE  5.   RELATION  OF  AGE  TO  DEGEN- 
ERATIONS. 


(E.)  Squamous  Carcinoma. 

Age  % 

20-30  0 

30-40  0.4 

40-50  0.3 

50-60  3 

60-70  4.6 


(A.)  Necrosis. 
Age.  % 

20-30  5 

30-40  7.7 

40-50  7.5 

50-60  9.3 

60-70  29 

(B.)   Calcareous  Degeneration.     (F.)   Sarcoma. 
Age.  %  Age.  % 

20-30  0  20-30  0 

.  30-40  2  30-40  0 

40-50  16  40-50  0.6 

50-60  14  50-60  3 

60-70  10  60-70  9.5 

(C.)   Hyaline  Degeneration. 

(G.)    Cho7-ioepithelioma. 
Age.  %  Age.  % 

20-30  11  20-30  0 

30-40  11.5  30-40  0 

40-50  16.8  40-50  0.6 

50-60  16.6  50-60  0 

60-70  10  60-70  0 

(D.)    Adenocarcinoma. 

(H.)    Total  Malignant   Tumors. 
Age.  %  Age.  % 

20-30  0  .  20-30  0 

30-40  0  30-40  0 

40-50  3.6  40-50  5 

50-60  6.3  50-60  12.7 

60-70  9.5  60-70  23.8 

Autopsies    26 

Heart  Lesions  at  Autopsy   11.5 

A  consideration  of  this  table  shows  that 
the  older  a  patient  the  more  danger  from 
the  fibroid  tumor.  The  older  the  patient 
the  greater  probability  there  is  of  malig- 
nant changes  and  other  dangerous  degen- 
eration, such  as  necrosis.  This  shows  that 
the  menopause  does  not  relieve  the  pa- 
tient from  danger  from  fibroids  save  from 
the  hemorrhage.  Other  and  more  danger- 
ous complications  remain  and  increase  in 
degree    with    each    succeeding   year. 

The  menopause,  which  does  not  come 
until  the  average  of  48  years  in  normal 
women,  according  to  Norris'  study,  is  com- 
monly delayed  longer  in  women  with 
fibroid  tumors  on  account  of  the  additional 


congestive  irritation  and  blood  supply  of 
the  tumors  in  the  uterus.  So  that  it  is 
not  fair  to  advise  a  woman  with  a  fibroid 
tumor  to  wait  until  45  years  for  a  meno- 
pause which  does  not  come  until  ^o  years, 
and  does  not  cure  when  it  does  arrive,  but 
brings  greater  dangers  with  it.  Opera- 
tion at  the  time  of  election  must  be  the 
treatment  of  fibroid  tumors  instead  of 
temporary  conservative  treatment  and 
operation  of  urgency  with  a  large  mortal- 
ity when  dangerous  symptoms  or  malig- 
nant complications  intervene. 

Malignant  change  took  place  in  5  per- 
cent, of  all  tumors.  Adenocarcinoma  of 
the  fundus  formed  the  greatest  part  of 
these  changes.  This  form  of  cancer,  as 
pointed  out  by  me  in  1904,  has  some  pre- 
dilection for  fibroid  tumors,  as  it  is  by  far 
the  most  common  form  of  malignant  asso- 
ciation. Fundal  cancer,  usually  in  other 
cases  than  fibroids,  is  found  about  one- 
sixth  as  frequently  as  squamous  carcinoma 
of  the  cervix,  while  with  fibroids  the  first 
is  found  more  than  three  times  more  fre- 
quently than  the  second. 

Apart  from  malignancy,  necrosis  is  pres- 
ent in  8  percent,  and  this  percentage  in- 
creases with  age.  Necrosis  must  increase 
the  mortality  at  operation,  and  cannot  ex- 
ist long  without  bacterial  contamination. 
Other  complications,  such  as  changes  in  the 
adjacent  viscera,  salpingitis,  appendicitis, 
etc.,  make  up  a  list  which  every  physician 
who  advises  against  operation  in  fibroid  tu- 
mors should  view  with  appreciative  alarm. 

The  dangers  from  fibroids  in  patients 
more  than  40  years  are  much  greater  than 
before  this  time.  If  operation  is  done  be- 
fore grave  complications  intervene,  the 
operation  may  be  one  of  choice  and 
with  a  low  mortality,  but  when  necroses, 


Page  Twenty-two 


malignant  changes  or  hemorrhage  compel 
operative  measures  in  a  weakened  patient, 
the  mortality  is  large. 

The  consideration,  therefore,  of  this 
series  of  fibroid  tumors  warrants  the  fol- 
lowing conclusions. 

1.  The  menopause  does  not  bring  a  cure 
to  fibroids ;  on  the  contrary,  increasing  age 
increases  the  danger  from  these  growths. 

2.  There  is  little  danger  of  malignancy 
arising  in  fibroids  before  the  fortieth  year 
of  the  patient,  after  which  time  the  danger 
increases  with  each  year. 

3.  In  view  of  the  sarcomatous  changes, 
carcinomatous  associations  and  other  de- 
generations of  uterine  fibromyomas,  early 
removal  is  indicated  when  they  are  of  suf- 
ficient size  to  produce  symptoms  and  cause 
the  patients  to  seek  advice.  Small  uncom- 
plicated fibroids  in  young  women  do  not 
require  early  treatment. 

4.  Thorough  pathologic  examination 
should  be  made  of  all  fibroids  for  evidence 
of  malignancy.  The  tumor  should  be  opened 
at  the  time  of  operation  and  examined  for 
adenocarcinoma  or  sarcoma.  Particular 
study  should  be  devoted  to  those  tumors 
.which  are  necrotic,  cystic,  or  both,  as 
among  these  are  found  the  largest  propor- 
tion of  malignant  changes. 

5.  In  view  of  the  large  percentage  of 
inflammatory  changes  in  the  Fallopian 
tubes  and  appendix,  these  should  be  ex- 
amined at  the  timiC  of  operation  and  re- 
moved, if  diseased. 

Previous   papers  on  fibroid  tumors: 
Ellice  McDonald,  M.  D. 

1.  Uterine  fibromyomata,  700  cases.  Jour, 
of  Ois.  and  Cfyn.  for  the  Brit.  Empire.  1909, 
Aug. 

2.  Flbromyoma  of  the  uterus  complicated 
by  cancer  or  sarcoma,  35  cases.  Jour.  Amer. 
Med.  Ass'n.  1908,  Mch.  20. 

3.  Complication  and  degeneration  of  uterine 
fibromyomata,  280  cases.  Jotcr.  Amer.  Med. 
Ass'n.     1904,  May   26. 


CHAPTER  V. 
A  NEW  OBSTETRICAL  FORCEPS. 

Introduction. —  Since  the  time  of  the 
Chamberlains,  there  has  not  been  any  very 
great  advance  in  design  of  obstetrical  for- 
ceps. Except  for  the  addition  of  the  pel- 
vic curve,  the  improvements  have  all  been 
made  in  the  manufacture  and  not  in  the 
design.  Tarnier's  axis  traction  principle 
v/as,  it  is  true,  a  new  one,  but  it  is  doubt- 
ful whether  the  effect  the  axis  traction 
forceps  was  made  to  attain — traction  in  the 
direction  of  the  axis  of  the  pelvis — cannot 
better  be  obtained  by  forceps  without  the 
axis  traction  mechanism.  In  other  words, 
with  a  properly  designed  pair  of  forceps,  if 
traction  in  direction  of  the  axis  of  the  pelvis 
cannot  be  obtained,  it  is  because  the  opera- 
tor does  not  know  the  axis  of  the  pelvis  and 
how  to  pull  in  it. 

The  chief  model  upon  which  most  mod- 
ern forceps  have  been  designed  is  the 
Simpson  model  of  which  the  Elliott  forceps 
is  the  best  type.  This  forceps  depends  for 
its  traction  upon  one  cross  piece  at  the 
end  of  the  forceps  (see  illustration)  for  its 
traction.  Were  this  cross  piece  removed 
and  the  forceps  to  consist  only  of  a  fork 
there  would  be  no  possibility  of  traction  at 
all.  In  other  words,  the  fenestrated  for- 
ceps of  the  Simpson  and  Elliott  type  de- 
pend for  their  traction  upon  a  friction  grip 
which  is  concentrated  in  one  part  of  the 
forceps — the  cross  bar  at  the  end. 

As  a  result  of  this  localization  of  the 
pressure  and  friction  in  one  part,  the  for- 
ceps must  be  narrow  within  the  points  to 
ensure  firmness  of  grip.  All  forceps, 
when  judged,  should  be  examined  in  the 
position  in  which  they  would  be  on  the 
child's  head — i.  e.,  with  their  largest  meas- 


Page  Twenty-three 


urement  of  separation  where  the  biparietal 
diameter  would  come.  The  ideal  of  for- 
ceps application  is  over  the  biparietal 
eminences.  The  average  biparietal  diam- 
eter is  9^  centimeters.  From  meas- 
urements, lead  tape  moulds  and  casts  of 
over  a  hundred  fetal  heads,  I  have  found 
that  when  the  forceps  are  over  an  average 
biparietal  diameter,  the  tips  must  be  sep- 
arated at  least  5>4  c.  m.  If  they  are  sep- 
arated less  than  this  they  cause  too  much 
pressure  over  the  stylomastoid  process  and 
the  tender  facial  nerve.  The  surest  way 
to  pass  an  opinion  on  a  pair  of  forceps  is 
to  open  them  to  g}i  c.  m.  and  measure  the 
tips.  A  proof  of  the  correctness  of  this 
assertion  is  that  three  investigators — Tar- 


danger  of  cutting  off  ears,  getting  forceps' 
scars,  fracture  of  the  skull,  gouging  out 
eyes,  causing  facial  paralysis,  and  all  the 
other  blood-thirsty  and  horrible  th^igs  that 
forceps  can  cause.  In  addition,  the  Simp- 
son type  forceps,  because  of  their  length, 
may  cause  injury  to  the  mother.  When  the 
traction  is  in  an  upward  direction,  as  it 
must  be  before  the  head  is  delivered  man- 
ually, the  long  blades  which  grasp  the  head 
over  the  biparietal  processes  pivot  upon 
these  processes,  and  the  tips  of  the  blades, 
projecting  beyond  the  head,  impinge  upon 
the  pelvic  floor  and  around  the  vaginal 
mucous  membrane  (Fig.  2).  This  may 
begin  a  perineal  laceration,  as,  when  the 
continuity  of  the  mucous  membrane  is  once 


Fig.  1.     Elliott  forceps — showing  traction  bar  beyond  the  black  mark. 


nier,  Elliott  and  myself — have  independent- 
ly come  to  the  conclusion  that  with  the 
average  sized  head,  the  forceps  tips  should 
be  separated  5^  c.  m.  for  all  three  designs 
have  this  measurement.  If  the  tips  are 
narrower  than  this,  undue  pressure  comes 
over  the  facial  nerve  with  consequent  in- 
crease in   facial  paralysis. 

While  the  Tarnier  and  the  Elliott  have 
the  same  proportion  in  this  measurement, 
on  account  of  the  pressure  and  friction 
traction  being  isolated  at  one  point,  the 
blades  have  to  be  longer  than  is  necessary 
with  my  forceps. 

With  the  long  blades  of  the  fenestrated 
forceps  of  the  Simpson  type,  there  is  more 


broken,  the  stretching  of  the  descending" 
head  causes  small  laceration  to  increase  in 
extent  just  as  a  small  tear  in  a  piece  of 
cotton  will  readily  extend.  This  is  shown 
in  a  study  of  perineal  lacerations  (Mc- 
Donald, Lacerations  of  the  Perineum,  Sur- 
gery Gyn.  and  Ob  St.,  Jan.,  1908)  in  which 
it  was  shown  that,  under  these  circum- 
stances, the  muscles  split  along  the  lines  of 
cleavage  after  the  mucous  membrane  and 
fascia  was  once  ruptured. 

If  the  fenestrated  blades  are  made  short- 
er than  the  Elliott,  they  won't  hold  unless 
undue  pressure  is  made.  The  Elliott  for- 
ceps is  the  best  design  of  its  type  as  is  at- 
tested by  thousands  in  use,  but  it  has  the 


Page  Twenty-four 


defects  of  its  type— pressure  localized  in 
one  spot,  blades  too  long-  and  too  broad. 
This  makes  the  forceps  difficult  to  apply 
and  often  causes  injury  to  the  mother. 
The  operation  of  rotation  of  the  head  by 
forceps  from  R.  O.  P.  is  difficult  with  the 
Simpson  type  forceps. 

Another  type  of  forceps  of  a  good  char- 
acter is  the  solid  blade  forceps,  of  which 
the  Tucker-McLane  forceps  is  the  best 
model.     These  forceps  have  the  advantage 


forceps  operation  they  will  slip,  or  else  so 
much  pressure  must  be  made  as  to  en- 
danger the  child. 

Description. —  With  the  idea  of  remedy- 
ing these  defects  and  including  the  ad- 
vantages of  both  the  Elliott  and  the  Tuck- 
er-McLane forceps,  I  have  devised  a  pair 
of  forceps,  which  have  as  their  basis  a  solid 
blade  into  which  a  number  of  slits,  win- 
dows or  fenestrae  are  cut.  The  blades  are 
shorter  than  either  of  the  other  models  and 


Fi.£ 


2.     Elliott  forceps — showing  extension  beyond  the  head  to  wound  the  mucous  membrane 

of  the  vagina. 


of  distribution  of  friction-pressure  and 
convenience  from  their  narrowness  of 
blade. 

As  a  result  of  the  broad  flat  smooth 
surface  of  the  blade  which  is  applied  to 
the  head,  the  friction-pressure  is  not  great. 
On  this  account  the  blades  must  be  made 
long  and  the  points  come  close  together  so 
that  they  will  hold.  For  this  reason,  the 
disadvantages  of  this  type  of  forceps  is  the 
length  of  blade  and  the  closeness  of  the 
tips.  These  forceps  are  very  nice  in  an 
easy  forceps  operation  with  a  normal 
head,  but  with   a  large  head  and   a  hard 


the  width  between  the  tips  the  same  as  the 
Elliott. 

The  multiple  fenestrae  do  not  detract 
from  the  strength  of  the  forceps  nor  from 
the  ease  of  application.  The  principle  is  of 
distribution  of  pressure  and  traction  by 
several  friction  points  instead  of  one  as 
the  Elliott  or  a  smooth  surface  as  the  solid 
bladed  Tucker-McLane.  The  principle  is 
that  of  the  non-skid  automobile  tire  where 
there  are  numerous  friction  ridges  or  of 
the  non-slipping  eye-glass  clips  where  in- 
stead of  one  bar  on  the  side  of  the  nose, 
there  are  two  or  several.      It  is  the  prin- 


Page  Twenty-five 


ciple  that  two  points  of  contact  can  make 
more  pressure  friction  than  one. 

As  a  result  of  this  non-sHpping  quality, 
there  can  be  certain  changes  in  the  blade 
which  are  desirable.  The  blades  may  be 
shorter  so  as  not  to  pinch  the  cord,  not  to 
make  too  much  pressure  low  down  over 
the  facial  nerve,  to  make  them  easy  to  ap- 


ways  be  found  to  be  caused  by  the  cross 
bar.  The  semi-fenestrated  forceps  will  not 
cut  off  any  ears  nor  are  they  likely  to  cause 
facial  paralysis.  They  are  desigr^d  to  in- 
clude the  best  qualities  of  the  fenestrated 
and  the  solid  blade  forceps. 

They  have  been  in  use  with  the  multiple 
fenestrae  since  1905.     I  have  had  nothing 


<r- 


37OW. 1  — 


jJi*    c/m. 


SA'e^. 


Fig.  3.     Author's  semi-fenestrated  forceps  with   multiple  traction  bars. 


ply,  to  make  them  easy  to  remove,  to  make 
the  operation  of  rotation  of  the  head  from 
R.  O.  P.  a  simple  one.  They  do  not  ex- 
tend beyond  the  head  and  cause  tears.  They 
do  not  slip.  They  do  not  cause  forceps 
scars  because  the  pressure  and  friction  are 
well  distributed.  If  the  forceps  scar  of 
an  Elliott  forceps  is   examined,  it  will   al- 


but  good  reports  from  them.  The  shortness 
and  narrowness  of  blade  makes  it  so  easy 
to  apply  them  that  they  may  be  more  often 
applied  to  the  sides  of  the  head  than  other 
forceps.  The  more  applications  over  the 
biparietal  eminences,  the  place  forceps  were 
meant  to  be  applied,  the  more  successful 
the  operations. 


Page  Ttoenty-six 


CHAPTER  VI. 

STERILIZATION  OF  THE  SKIN. 

Introduction. —  Sterilization  of  the  skin 
before  operation  is  a  problem  which  was 
not  solved  by  Grossisch's  tincture  of  iodine 
method.  This,  although  a  great  advance, 
has  the  disadvantage  of  not  being  a  good 
fat  solvent  and  causing  considerable  irrita- 
tion. The  tincture  of  iodine  method  has 
another  disadvantage  in  that  it  must  be  ap- 
plied by  painting  with  the  result  that  the 


Description     of     A"uthor's     Method. — 

In   order   to   obviate   the   disadvantages   of 
the  tincture  of  iodine  solution  I  have  used 
the  following  solution  for  four  years,  and 
have  already  reported  results^. 
Author's'  solution: 

Iodine    2% 

Carbon    tetrachloride    9^% 

This  solution  has  all  the  advantages  of 
the  tincture  without  the  disadvantages,  and 
may  be  applied  without  previous  washing. 
The  longer  application  makes  up  for  the 


Fig.  4. 


Author's  method  of  producing  traction  in  the  direction  of  the  pelvic  axis  and  modified 

Pajor's  maneuvre. 


aid  of  the  mechanical  effect  of  rubbing  and 
scrubbing  is  not  obtained  as  an  aid  to  the 
penetration  of  the  antiseptic.  Of  one  hun- 
dred and  thirteen  surgeons  at  the  German 
Surgical  Congress,  twenty-eight  com- 
plained of  the  eczema  following  the  tinc- 
ture of  iodine  method.  This  irritation  is 
due  to  the  fact  that  the  iodine  method  is 
supplemented  by  other  mechanical  meth- 
ods as  the  tincture  cannot  be  rubbed  in. 
Almost  all  the  surgeons  reduced  the 
strength  of  the  tincture  to  5  percent. 


weaker  solution.  The  solution  is  rubbed 
with  a  piece  of  gauze  over  the  skin  for  two 
minutes  after  the  part  has  been  shaved 
upon  the  table  or  the  night  previously. 

The  solution  is  not  explosive,  non-irri- 
tating, and  cheap.  Carbon  tetrachloride  is 
a  heavy  colorless  liquid  not  unlike  chloro- 
form. It  has  itself  considerable  germi- 
cidal value  and  is  a  fat  solvent.  It  is  ad- 
vertised under  a  trade  name  as  a  popular 

^McDonald,  Ellice:  Sterilization  of  the  Skin. 
Med.  Rec,  1911,  Apr.  15. 


Page  Tiventy-seven 


non-explosive  cleansing  fluid  for  clothes. 

The  solution  has  the  advantage  of  being 
a  fat  solvent,  of  being  non-inflammable,  of 
being  not  irritating,  and  the  skin  may  be 
scrubbed  with  it  so  that  all  the  benefit  of 
mechanical   cleansing  may  be  obtained. 

No  other  method  need  be  combined  with 
it.  Bichloride  with  iodine  solutions  forms 
an  irritating  mixture.  All  iodine  solutions 
should  be  prepared  fairly  fresh — not  more 
than  three  weeks  old.  The  stains  of  iodine 
may  be  removed  by  sodium  hyposulphite 
(thiosulphate). 

Whatever  solution  is  used  for  skin  steril- 
ization, it  must  be  a  fat  solvent.  If  a  so- 
lution does  not  dissolve  fat,  there  can  be 
no  hope  of  its  penetration  into  the  mouths 
of  the  sweat  glands  and  the  recesses  of  the 
skin.  A  globule  of  fat  may  prevent  the 
penetration  of  the  antiseptic  and  conceal 
bacteria  which  later  manipulation  and  ex- 
cretion may  expose.  It  is  also  necessary 
for  the  same  reason  that  every  skin  germi- 
cidal solution  should  be  capable  of  being 
rubbed  into  the  skin,  so  that  the  mechan- 
ical manipulation  may  break  down  any 
barrier  of  fat,  perspiration  or  other  detri- 
tus and  allow  the  chemical  action  of  the 
germicide   full   play. 

According  to  Beekman^  at  the  Mayo 
Clinic,  BastionelH's  method  is  used,  iodine 
in  benzine  i-iooo  (Heusner's  solution)  fol- 
lowed by  three  and  one-half  percent  tinc- 
ture of  iodine  painted  on  the  skin.  My  so- 
lution has  the  advantage  of  combining  these 
two  processes  into  one,  and  has  a  high 
germicidal  value  as  the  carbon  tetrachloride 
is  more  germicidal  than  benzine,  or  alcohol, 
and  much  less  irritating  than  benzine. 
Heusner  himself,  the  author  of  the  benzine 
solution  has  added  paraffin  to  it  in  order 
to  reduce  the  irritating  qualities. 

^Beekman:     Interstate  Medical  Journal,  1912. 


CHAPTER  VII. 

PREPARATION    OF    CATGUT    LIGA- 
TURES. 

Good  ligatures  are  one  of  the  first  req- 
uisites of  good  surgery.  The  ideal  liga- 
ture should  be  strong,  sterile  and  soft.  Cat- 
gut has  up  to  the  present  time  proven  itself 
to  be  the  most  applicable  for  surgical  pur- 
poses. The  problem  in  the  preparation  of 
catgut  is  to  ensure  sterility  without  a  loss 
of  strength  and  pliability. 

The  catgut  is  rawhide  tissufe  or  untanned 
leather,  and  like  all  such  material  will  swell 
in  size  on  the  addition  of  water,  or  a  water 
bearing  solution,  such  as  alcohol.  The  cat- 
gut being  animal  tissue  also  contains  fat, 
and  it  is  essential  for  sterility  that  this  fat 
be  removed  as  unless  this  is  done  the  fat 
may  harbor  bacteria  and  so  cause  contam- 
ination. For  this  reason  the  sterilizing 
solution  must  be  a  fat  solvent.  The  gut 
must  remain  the  same  size  as  before  steril- 
ization and  not  increased  in  size  as  is  done 
by  alcohol  or  alcohol  bearing  solutions — so 
that  when  the  gut  dries  it  becomes  hard  and 
stiff,  and  while  wet  is  slippery  and  inelastic. 

After  considerable  experimentation  the 
following  process  has  been  adopted.  It  was 
published  two  years  ago,  and  since  then 
continuous  experiment  has  not  altered  the 
method.  I  have  had  good  reports  from  a 
number  of  hospitals  about  the  method. 

In  order  to  completely  obviate  any  faint 
possibility  of  tetanus  contamination,  it  is 
well  to  sterilize  the  catgut  in  gross  as  it 
comes  from  the  maker  by  cooking  in 
paraffin  oil  at  2i2°-240°  for  half  an  hour. 
Care  should  be  taken  not  to  run  the  tempera- 
tures too  high  as  it  makes  the  gut  brittle. 
It  should  be  cooked  upon  a  sand  bath  and 
the  gut  should  be  suspended  in  the  oil  so 
that  none  touches  the  sides  of  the  vessel. 


Page  Ttoenty-eigM 


The  gut  in  loo  ft.  rolls  may  be  cooked 
and  then  taken  out  and  cut  into  desired 
lengths  or  stored  before  placing  in  the 
iodine-acetone  solution. 

Wide  mouth  jars  with  ground  glass  tops 
or  preserve  jars  may  be  used  for  the  prep- 
aration of  the  gut.  My  custom  is  to  cut 
the  gut  into  30  inch  strands  and  roll  4 
strands  together  in  rolls  of  a  diameter  of 
about  2  inches,  wrapping  the  ends  four 
times  around.  In  this  way  the  total  amount 
for  a  laparotomy  may  be  easily  placed  in 
one  small  jar  and  much  handling  avoided. 

author's  method. 

1.  Cook  in  paraffin. 

2.  Iodine,  3  per  cent 
Acetone  (commercial),  97  per  cent. 

for  8  days. 

3.  Acetone,  100  per  cent.,  8  days. 

4.  Preserving  solution : 

Acetone,  85  per  cent. 

Columbian  spirits,  10  per  cent. 

Glycerine,  5  per  cent. 

The  glycerine  should  be  dissolved  in  the 
alcohol  and  added  to  the  acetone. 

These  solutions  are  fat  solvent  and  anti- 
septics. The  final  product  is  smooth,  soft 
and  elastic.  The  ligatures  are  the  same 
size  as  the  raw  gut  and,  when  used,  ab- 
stract water  from  the  tissues,  which 
caused  the  knot  to  become  firmly  welded  and 
so  avoids  the  tendency  to  unravel  which  is 
associated  with  the  alcohol  stored  gut.  The 
final  cost  is  about  i  cent  a  foot,  and  a  lap- 
arotomy may  be  done  with  a  catgut  cost  of 
less  than  twenty-five  cents. 

The  choice  of  the  raw  gut  is  of  impor- 
tance. It  should  be  soft,  strong  and  un- 
bleached. The  qualities  desired  in  the  steril- 
ized product  should  be  looked  for  in  the 
raw  gut.  Gut  which  is  clear  and  translucent 
like  violin  strings  is  not  good  for  ligature 


material  and,  if,  on  pinching  the  gut,  a 
white  mark  or  crack  appears  it  is  a  sign 
that  the  gut  contains  too  much  fat  or  that 
the  gelatinous  portion  is  firmly  coagulated 
and  that  it  will  not  make  soft  ligatures. 

The  method  is  simple  and  inexpensive. 
The  ligatures  are  only  handled  once  when 
they  are  put  in  the  bottle.  They  will  keep 
indefinitely  provided  the  final  solution  con- 
tains no  iodine :  for  continuous  storage  in 
iodine  solution  will  destroy  any  gut.  If  it 
is  required  to  store  the  gut  for  more  than 
one  year  the  gut  should  have  two  wash- 
ings in  the  preserving  solution. 


CHAPTER  VIII. 
DIAGNOSIS  OF  EARLY  PREGNANCY. 

The  diagnosis  of  pregnancy  is  one  which 
must  be  settled  positively  or  negatively  in 
every  woman  patient  who  consults  the  phy- 
sician. Without  this  it  is  impossible  to  in- 
telligently diagnose  and  treat  her  ailment. 
If  she  is  outside  the  child-bearing  age,  then 
the  exclusion  of  pregnancy  is  not  difficult, 
but  between  15  and  50  years  of  age  it  is 
often  a  difficult  question  to  eliminate  preg- 
nancy. 

This  must  be  done  before  any  operation 
is  undertaken,  and  almost  every  operator 
has  had  the  experience  of  finding  at  opera- 
tion an  unexpected  pregnancy.  Unfortunate 
the  surgeon  who  thus  errs !  He  is  held  in 
execration  by  his  patient  and  in  derision  by 
his  colleagues.  Yet  the  literature  is  full  of 
such  mistakes,  although  it  is  safe  to  say 
that  the  great  majority  are  not  published. 
Van  der  Veer,  in  1889,  collected  'j'j  cases  of 
abdominal  section,  in  which  unsuspected 
pregnancy  occurred.  I  have  been  told,  or 
have  heard  of  at  second  hand,  fully  an  equal 
number  of  cases,  many  of  them  in  the  hands 


Fage  Ttventy-nine 


of  most  erudite  and  skillful  physicians. 
This  shows  how  difficult  is  the  diagnosis  of 
early  pregnancy  and  how  easy  it  is  to  make 
mistakes  in  regard  to  it. 

The  diagnosis  of  early  pregnancy  must 
depend  upon  the  findings  by  vaginal  ex- 
amination, because  the  history  is  often  in- 
exact and  the  breast  signs  appear  too  late 
to  be  of  value.     Of  the  symptoms  of  preg- 


regular  to  the  day,  but  if  her  menstruation 
has  been  irregular  in  time,  then  the  sign 
is  of  no  value  whatever.  Pregnancy  may 
take  place  in  the  absence  of  mengtruation, 
before  puberty,  in  the  amenorrhea  of  lacta- 
tion, or  in  those  who  are  in  the  habit  of 
missing  periods.  Amenorrhea  may  occur 
after  wasting  diseases,  tuberculosis,  in 
acromegaly,  tumors  of  the  brain,  particu- 


Fig.  1.     Jacquemin's  spot. 


nancy,  nausea  and  vomiting,  and  cessation 
of  menstruation  are  the  most  important. 
Nausea  occurs  in  only  about  half  of  all 
cases  and  is  more  frequently  found  in  el- 
derly primiparae.  It  may  be  caused  by 
other  conditions  and  is  only  of  corrobora- 
tive value  in  the  diagnosis  of  pregnancy. 

Cessation  of  menstruation  is  of  value  as 
a  sign  of  pregnancy,  if  the  woman  has  been 


larly  those  of  the  hypophysis  cerebri,  frac- 
tures of  the  skull,  sexual  infantilism  and 
the  premature  menopause.  Menstruation 
may  be  stopped  by  change  of  climate  and 
environment,  as  frequently  in  Irish  girls 
coming  to  this  country.  So  cessation  of 
menstruation  is  of  value  in  the  diagnosis  of 
pregnancy,  if  the  woman  has  been  pre- 
viously absolutely  regular,  otherwise  it  is 


Page  Thirty 


of  no  value  as  a  diagnostic  sign. 

Signs   on  Vaginal   Eixamination. — The 

diagnosis  of  early  pregnancy  must,  after 
all,  depend  upon  vaginal  examination.  The 
conditions  caused  by  pregnancy  of  growth 
and  increased  vascularity  of  the  uterus 
must  first  have  their  effect  upon  the  uterus 
itself  and  the  pelvic  organs.  The  changes 
may  first  be  expected  in  the  uterus  itself, 
then  in  the  vagina  and  the  adjacent  parts. 
The  signs  of  pregnancy  may  be  divided  into 

1,  the  congestive  signs,  i.  e.,  blush  and  flush 
of  the  vaginal  mucous  membrane,  blush  of 
the  cervix  and  softening  of  the  cervix,  and 

2,  uterine  signs,  including  enlargement  of 
uterus,  softening  of  the  uterus,  inter- 
mittent uterine  contractions,  Hegar's  signs 
and  the  author's  sign. 

This  study  is  based  upon  150  cases  care- 
fully examined  with  respect  to  these  signs, 
of  which  100  cases  were  previously  re- 
ported. 

The  duration  of  the  pregnancy  was  cal- 
culated from  the  date  of  the  last  menstrua- 
tion. This  may  cause  a  mistake  in  the 
calculation  of  the  length  of  time  of  preg- 
nancy, but  it  is  the  only  date  which  can 
be  absolutely  fixed. 

Great  care  was  taken  in  the  examination 
of  these  women  in  order  that  any  tendency 
to  error  might  be  avoided.  The  diagnosis 
in  the  early  weeks  is  one  which  must  de- 
pend upon  exactitude  and  skill  in  vaginal 
examination.  It  is  of  the  greatest  impor- 
tance that  the  bladder  should  be  emptied. 
If  any  urine  remains  within  the  bladder,  it 
is  impossible  to  appreciate  any  minor 
changes  in  the  size,  shape  and  consistency 
of  the  uterus.  The  fundus  cannot  be  ac- 
curately outlined  and  the  intermittent  con- 
tractions of  the  uterus  cannot  be  felt. 

The  waist  bands  should  be  loosened  and 
the  patient  in  good  position  with  the  hips 


well  elevated  upon  an  examining  table  or 
a  hard  bed.  If  necessary,  a  board  should 
be  put  under  the  bed.  The  operator  should 
be  in  an  easy  position  and  one  in  which  he 
may  be  able  to  hold  his  examining  hands 
perfectly  still  over  a  period  of  minutes  in 
order  to  properly  appreciate  the  intermit- 


Fig.  2.     Asymmetrical  enlargement. 


tent  uterine  contractions.  The  length  of 
vaginal  examination  should  extend  over 
sufficient  time  to  recognize  two  contractions 
of  the  uterus  with  the  intervening  relaxa- 
tion. This  is  usually  from  five  to  ten 
minutes.  If  the  patient  is  upon  an  exam- 
ining table,  one  should  rest  one's  foot  upon 
a  stool  or  step,  and  the  arm  upon  the  thigh 
in  order  to  have  proper  control  of  one's 
hand.  If  the  patient  is  upon  a  bed,  the 
elbow  may  be  rested  upon  the  mattress.  In 
this  way,  it  is  possible  to  take  all  muscular 
strain  off  the  examining  hand  and  more 
delicately  appreciate  any  of  the  more 
minute  pelvic  changes.  The  greatest  pos- 
sibility of  error  is  in  making  too  hurried  an 


Page   Thirty-one 


examination  and  in  finding-  a  uterus  in  one  taught  in  1837  by  Jacquemin.  In  the  ex- 
phase  of  its  contraction  or  relaxation,  so  amination  of  4,500  prostitutes  in  compliance 
masking  other  signs.  with  police  regulations  of  Paris,  he  ob- 
The  cases  are  arranged  in  regard  to  the  served  that  this  violet  hue  of  the  vagina 
duration  of  pregnancy  and  to  the  number  of  was  present  very  early  in  cases  of  preg- 
times  each  sig-n  was  found.  No  case  was  nancy.  This  violet  hue  or  blush  of  the 
included  in  the  series,  unless  the  author  vagina  was  likened  by  Jacquemin  to  the  lees 
was  convinced  that  it  was  a  pregnancy,  and  of  urine  or  claret  at  the  bottom  of  the  cask. 
not  some  condition  simulating  it.  When  In  this  series,  it  was  found  that  the  sign 
Hegar's  sign,  the  intermittent  contractions  was  observed  in  about  two-thirds  (57%) 
of  the  uterus,  softening  of  the  cervix,  and  of  all  cases  before  the  thirteenth  week.     It 

TABLE  OF  100  CASES  ARRANGED  IN  PERCENTAGE. 

Week  of  Pregnancy   5       6       7       8       9     10     11     12     13       Total 

Number    of    Cases:  6       8     12     12     15     15     12     12       8          100 

Enlargement  of  Uterus: 

Symmetrical    0       4       9       3       9       3       9     11       5             53 

To   the  left    2       1       2       3       3       6       2       0       2             21 

To  the  right   4       3       1       6       3       6       1       1       1             26 

Softening  of  the  Uterus: 

Symmetrical 0       4       9       3       9       3       9     11       5             53 

On    the    left    2       1       2       3       3       6       2       0       2             21 

On   the    right    4       3       1       6       3       6       1       1       1             26 

Jacquemin' s   Sign : 

Slightly   0       2       3       6       9       4       2       4       4             34 

Markedly     0       0       0       3       0       6       6       4       4             23 

Absent   6       6       9       3       6       5       4       4       0             43 

Cervix  Blush: 

Present 2       1       3       6       9     10     10     12       8             61 

Absent   4       7       9       6     10       5       2       0       0             39 

Cervix  Softening: 

Present    2       2       6       6       8     12     10     12       8             66 

Absent  4       6       6       6       7       3       2       0       0             34 

Hegar's  Sign: 

Absent   2       1       3       0       0       0       0       0       0               6 

Moderately   2       6       6       6       9       8       4       3       1             45 

Definitely    2       1       3       6       6       7       8       9       7             49 

Intermittent   Contractions: 

Present    3       6     12     12       9     13     11     12       8             88 

Absent  3       2       0       0       4       2       1       0       0             12 

Author's  Sign  of  FlexiMlity  of  Lower  Segment: 

Definitely    2       6       8       9     12     12     10     10       8             76 

Moderately   2       2       3       3       4       3       2       2       0             21 

Absent   2       0       1       0       0       0       0       0       0               3 

the  author's  sign  of  flexibility  of  the  lower  was  present  less  often  in  the  early  weeks 

uterine  segment  were  present,  the  diagnosis  and  more  often  in  the  later  ones,  as  may  be 

was  considered  exact.     The  cases  are  ar-  seen  from  the  table.     It  is  almost  constantly 

ranged  in  a  table  of  100  cases  showing  the  present    at   the   thirteenth    week.     This    is 

percentage  of  the  finding  of  the  signs  and  because,   as  pregnancy  advances,  the  con- 

the   weeks   at   which  they   occurred.     The  gestion  increases,  and  so  in  the  early  weeks 

additional  cases  bear  out  the  table.  congestion  is  small  and,  as  time  goes  on, 

Congestive    Signs.i —  Jacquemin' s     Sign,  it  becomes  greater. 

— This  sign  of  bluish  tinge  of  the  vaginal  It  was  found  that  this  congestion  of  the 

mucous  membrane  is  one  which  was  first  vagina  began  as  a  rule  at  a  spot  about  2 

Page  Thirty-two 


cm.  or  a  thumb's  breadth  below  the  orifice 
of  the  urethra.  From  this  spot,  the  con- 
gestion and  violet  hue  spread  over  the 
vagina.  This  I  have  called  Jacquemin's 
spot  after  the  discoverer  of  the  sign  of 
blush  of  the  vagina.  The  violet  color  does 
not  show  at  first  upon  the  surface  of  the 
mucous  membrane ;  but  as  here  the  mucous 
membrane  has  creases  and  crevices,  the 
sign  is  seen  as  streaks  of  livid  bluish  pur- 


The  cervical  blush  was  present  in  about 
two-thirds  of  the  cases,  seldom  in  the  early 
weeks  and  more  constantly  as  pregnancy 
advanced,  as  may  be  seen  from  the  table. 
Softening-  of  the  Cervix. — Softening  of 
the  cervix  was  noticed  in  about  the  same 
proportion  as  blush  of  the  cervix  in  about 
two-thirds  (66  per  cent.)  of  cases.  The 
sign  as  may  be  seen  from  the  table  was  not 
reliable   until   after   the  tenth   week.     The 


Fig.  3.    Hegar's  sign. 


pie  at  the  bottom  of  these  furrows.  The 
phenomenon  may  be  best  seen  at  its  first 
appearance  by  separating  the  labia  and 
stretching  the  mucous  membrane,  so  that 
these  creases  may  be  opened  and  the  en- 
gorged veins  exposed. 

Blush  of  Cervix. —  The  violet  hue  of  the 
cervix,  also  due  to  congestion,  is  usually 
a  more  satisfactory  sign,  than  that  of  blush 
of  the  vagina.  It  is  more  definite  and  more 
frequently  found.  The  changes  of  preg- 
nancy can  be  depended  upon  to  show  in  the 
uterus  before  they   appear   in  the  vagina. 


softening  seemed  first  to  occur  from  with- 
out inwards,  the  mucosa  becoming  con- 
gested and  velvety  soft,  while  the  hard 
core  of  cervical  tissue  could  be  felt  within. 
The  cervix  later  increased  in  softness 
throughout. 

The  softening  of  the  cervix  also  involves 
the  isthmus  of  the  uterus  and  so  has  some 
effect  upon  the  position  of  the  cervix.  The 
cervix  in  the  non-pregnant  lies  at  an  angle 
across  the  vagina,  but  with  the  softening 
of  pregnancy  this  angle  is  not  maintained; 
the  pressure  of  the  vaginal  walls  causes  a 


Page  Thirty-three 


bend  in  the  isthmus  so  that  the  cervix 
comes  to  be  more  in  the  axis  of  the  vagina. 
This  is  in  itself  sug"g"estive  of  pregnancy 
that  the  cervix  should  be  in  the  same  axis 
as  the  vagina. 

These  congestive  signs  of  change  in 
color  and  consistency  of  the  vagina  and 
cervix  are  readily  caused  by  any  congestive 
condition  save  pregnancy  and  are  very  re- 
liable in  its  diagnosis  after  the  twelfth 
week  of  gestation.     Before  that  time  they 


symmetrical,  but  occurs  in  one  or  other 
horn  of  the  uterus.  In  the  early  weeks  the 
enlargement  is  not  accompanied  by  com- 
plete softening  of  the  uterine  tissfte,  but  is 
somewhat  softened  with  scattered  hard 
spots  or  islands  of  firm  tissue,  giving  an 
impression  not  unlike  a  very  soft  uterus 
with  small  firm  nodular  fibroids. 

The  enlargement  and  softening  usually 
progress  together  and  are  more  asymmet- 
rical in  the  earlier  weeks,  but,  as  growth 


Fig.  4.     Hegar's  sign. 


are    unreliable,    although    offering    strong 
corroborative  evidence. 

Changes  in  the  Uterus. — The  growth  of 
the  physiological  tumor  occurring  as  it 
does  in  the  uterus,  it  is  here  that  the  first 
changes  caused  by  gestation  may  be  felt. 
Uterine  enlargement  is  one  of  the  first  signs 
of  pregnancy,  and,  without  it,  no  positive 
diagnosis  of  pregnancy  should  ever  be 
made.     The  enlargement  is  not,  as  a  rule, 


continues,  the  uterus  becomes  more  and 
more  symmetrical  until,  after  the  tenth 
weeks  of  pregnancy  may  become  almost  an 
ovoid. 

This  asymmetry  of  the  uterus  in  the  early 
weeks  of  pregnancy  may  become  almost  a 
distortion  and  may  give  rise  to  grave  errors 
of  diagnosis.  It  is  likened  to  a  face  swollen 
from  an  inflamed  tooth  and  on  account  of 
the  softness  and  apparent  detachment  from 


Page  Thirty-four 


the  uterus,  is  not  infrequently  mistaken  for 
ectopic  pregnancy.  The  firm  spots  or 
nodules  disappear  after  the  early  weeks 
and  are  believed  to  be  due  to  the  firm 
uterine  tissue  undergoing  softening  from 
the  spread  of  congestion  along  the  blood 
vessels. 

The  enlargement  of  the  uterus  is  asym- 
metrical in  more  than  half  of  the  cases.  It 
is  seldom   symmetrical  before  the  seventh 


firm  spots  or  buttons.  These  firm  spots 
disappear  about  the  tenth  week. 

The  softening  and  the  enlargement  of 
the  uterus  are  usually  situated  upon  one  or 
other  corner  of  the  fundus  and  marked  off 
from  the  firmer  unenlarged  part.  The  firm 
edge  of  the  normal  uterus  tissue  is  very 
distinctly  palpable. 

Where  there  is  retroversion,  the  conges- 
tive signs  of  flush  of  vagina,  etc.,  are  more 


Fig.   5.      Author's  sign  of  flexibility  of 

week  and  more  commonly  symmetrical 
after  the  tenth  week  after  the  last  present 
menstruation.  In  other  words,  as  preg- 
nancy advances,  the  asymmetrical  uterus 
becomes  more  and  more  symmetrical. 

Softening  of  the  uterus  is  a  sign  which 
should  be  taken  with  that  of  enlargement 
and  is  present  in  the  same  proportion  of 
cases.  The  softening  usually  takes  the 
form  of  an  elastic  doughiness  with  isolated 


the   isthmus  of  the  uterus — Hinge  sign. 

marked  and  the  softening  of  the  uterus  is 
increased  out  of  proportion  to  the  duration 
of  pregnancy.  The  congestion  of  preg- 
nancy has  added  to  it  the  congestion  of  the 
retroversion  of  the  uterus. 

The  enlargement  and  softness  of  the 
uterus  is  often  joined  with  a  marked  thin- 
ning of  the  uterine  wall. 

Intermittent  Uterine  Contractions. — 
These  contractions  were  studied  by  Brax- 


Page  Thirty-five 


ton  Hicks  and  believed  by  him  to  exist  only 
in  later  pregnancy,  but  they  occur  con- 
stantly in  earlier  pregnancy  and  are  always 
present  upon  vaginal  examination.  To  be 
properly  appreciated,  the  bladder  must  be 
empty  and  the  patient's  waistbands 
loosened. 

The  manipulation  of  the  fingers  upon 
vaginal  examination  are  sufficient  to  cause 
a  contraction,  so  that  by  the  time  the  ex- 
amination begins,  a  contraction  is  present. 
This  contraction  usually  lasts  from  one  to 
three  minutes  and  is  followed  by  a  stage  of 
relaxation  of  longer  duration.  The  con- 
traction involves  the  whole  uterus,  includ- 
ing the  lower  uterine  segment  and  cervix. 
The  change  in  color  of  the  cervix,  from 
pale  violet  to  a  normal  pink  hue,  caused  by 
the  contraction,  may  sometimes  be  seen 
through  a  speculum  and  in  a  good  light. 

These  intermittent  contractions  are  a 
constant  accompaniment  of  pregnancy  and 
influence  the  value  of  the  other  signs 
because  the  contraction  of  the  uterus  make 
it  firmer  and  so  makes  it  difficult  to  appre- 
ciate the  softening  and  enlargement  and  to 
elicit  Hegar's  and  the  author's  signs.  For 
this  reason,  these  signs  should  be  obtained 
during  the  interval  of  relaxation. 

The  uterus  becomes  smaller,  harder  and 
more  erect.  It  becomes  shorter  and  firmer. 
The  softened  part  also  contracts,  but  not 
so  firmly,  as  the  rest  of  the  uterus.  There 
is  no  irregularity  of  contraction,  but  the 
thinner,  softer  part  contracts  less  forcibly. 

Intermittent  contractions  are  believed  by 
the  author  to  be  a  constant  accompaniment 
of  early  pregnancy.  The  percentage  of 
elicitation  may  be  seen  from  the  table;  this 
is  due  to  the  fact  that  in  the  earlier  cases, 
the  value  of  the  sign  was  not  appreciated. 
Uterine  contractions  also  occur  sometimes 


before  menstruation,  in  submucous  fibroids, 
and  sometimes  in  ectopic  pregnancy. 

Hegar's  Sign  of  Compressibility  of  the 
Isthmus. —  This  sign  depends  sapon  the 
softening  in  the  isthmus  due  to  the  increas- 
ing congestion.  Hegar  advised  one  finger 
in  the  rectum,  but  it  is  best  obtained  by  two 
fingers  in  the  anterior  vaginal  fornix, 
while  the  other  hand  is  behind  the  fundus. 
When  a  relaxation  of  the  uterus  is  present, 
preferably  just  after  a  contraction,  the  in- 
ternal or  vaginal  fingers  are  thrust  upwards 
and  forwards  in  the  direction  of  the  pa- 
tient's umbilicus.  The  isthmus  will  be  felt 
to  give  or  stretch  like  a  stout  elastic  band. 
The  upper  fingers  press  down  at  the  same 
time  and  control  the  maneuvre.  This  sign 
is  very  exact,  as  may  be  seen  from  the 
table.  It  is  present  in  certain  other  condi- 
tions, but  on  the  whole  is  very  accurate. 

Author's  Sign  of  Flexibility  of  the 
Isthmus — Hinge  Sign  of  Pregnancy. — 
This  sign  also  depends  upon  the  softening 
and  vascularity  of  the  lower  uterine  seg- 
ment, but  it  can  be  appreciated  before 
Hegar's  sign  of  compressibility  and  thin- 
ning  (" Weichheit,  Nachgiebigkeit  und 

Verdunnung  des  tmtern  Uterussegments") . 
The  vascularity  which  causes  both  signs 
allows  flexibility  before  compression  and 
thinning  of  the  lower  segment. 

To  obtain  the  sign,  the  bladder  must  be 
empty  and  the  waistbands  loosened.  One 
hand  is  placed  upon  the  abdomen  and  the 
tips  of  the  fingers  press  upon  the  posterior 
part  of  the  fundus.  The  palmar  surfaces 
of  the  fingers  in  the  vagina  rest  under  the 
posterior  aspect  of  the  cervix.  The  uterus 
should  be  in  a  state  of  relaxation.  The 
fingers  of  both  hands  are  then  pressed  to- 
gether as  if  to  make  the  fundus  and  cervix 
meet.       The  fundus  and  cervix  then  come 


Page  Thirty-six 


easily  toward  each  other,  as  if  the  isthmus 
of  the  uterus  were  a  well  oiled  hinge.  The 
fundus  is  pressed  downwards  and  the  cervix 
drawn  upwards,  as  if  to  make  the  tips  of 
the  fingers  of  each  hand  meet.  The  uterus 
may  often  be  completely  doubled  upon 
itself,  although  flexibility  of  the  isthmus  is 
in  itself  an  expression  of  the  sign.  In  re- 
troversion the  sign  may  be  obtained  by 
pushing  the  cervix  backwards.  The  sign 
was  present  in  97  per  cent,  of  cases. 

Other  signs  of  pregnancy  as  the  "jug" 
sign,  where  they  depend  upon  increased 
growth  in  the  uterus,  are  of  value  later  in 
pregnancy.  Pulsation  of  the  arteries,  etc., 
have  no  constant  value.  A  soft  or  fluctuat- 
ing spot  upon  the  anterior  wall  of  the 
uterus  is  of  no  value  in  the  early  diagnosis, 
although  present  after  the  third  month. 
The  irregularity  of  softening  and  enlarge- 
ment make  any  one  spot  uncertain. 

The  diagnosis  of  early  pregnancy  must 
depend  upon  no  one  sign,  but  upon  the  con- 
joined evidence  of  all  signs.  The  con- 
gestive signs  of  flush  of  the  vagina,  etc., 
offer  reliable  evidence  after  the  third 
month,  but  are  of  no  great  use  before  the 
ninth  week. 

The  diagnosis  of  early  pregnancy  must 
depend  upon  the  changes  in  the  uterus  from 
the  growing  ovum — irregular  enlargement, 
symmetrical  or  otherwise,  intermittent  con- 
tractions, Hegar's  sign  and  the  author's 
sign. 

These  last  two  signs  of  compressibility 
and  flexibility  of  the  isthmus  with  enlarge- 
ment and  irregular  contraction  allow  of  a 
positive  diagnosis  being  made  within  ten 
days  after  the  missed  menstruation  and 
increase  the  ease  of  positive  diagnosis  at  a 
later  period. 


CHAPTER  IX. 

PUERPERAL  INFECTION  FROM  THE 
GONOCOCCUS. 

With  Report  of  a  Case  of  Death  from 
Gonococcus  Puerperal  Infection  and 
a  Resume  of  17  Previously  Re- 
ported Cases. 

Puerperal  infection  is  a  disease  which  is 
usually  associated  in  thought  with  strepto- 
coccus infection  and  such  a  commonly  in- 
fecting organism  as  the  gonococcus  is  over- 
looked. This  infection  is  probably  the  most 
frequent  form  of  infecting  organism  in 
maternity  practice.  Bumm  states  that  ap- 
proximately one-third  of  all  his  clinic  cases 
have  gonococcus  infection.  Stone  and 
myself,^  in  our  report  of  17  cases  found 
that  gonococcus  infection  was  present 
in  at  least  ten  per  cent,  of  our  cases,  when 
only  selected  cases  were  chosen  for  bac- 
teriological examination,  and  undoubtedly 
more  than  this  percentage  were  infected. 

The  chief  difficulty  in  the  study  of  gono- 
coccus puerperal  infection  is  the  difficulty 
of  its  bacteriological  study.  Cultural 
methods  have  only  recently  been  made  ap- 
plicable to  the  gonococcus.  This  difficulty 
has  been  due  to  the  frequency  with  which 
it  occurs  in  association  with  other  organ- 
isms, particularly  the  colon,  and  the  fact 
of  the  difficulty  of  obtaining  it  in  swab 
lochia  cultures  early  in  the  infection,  when 
intrauterine  cultures  are  usually  taken. 
However,  with  a  better  knowledge  of  its 
cultivation  and  the  method  of  taking  cul- 
tures for  this  organism,  it  is  being  more 
accurately  studied. 


^Stone    and    MacDonald,    Surgery,    Gyn.    and 
Oist.,  Dec,  1905. 


Page  Thirty-seven 


Gurd^  has  shown  that  cultures  of  the 
gonococcus  will  grow  well  upon  hemo- 
globin agar  of  a  titer  from  .6  to  .8  per 
cent,  phenolphthalein  (hot  titration).  He 
has  also  shown  that  it  is  often  useless  to 
make  cultures  from  the  fluid  lochia  or  pus, 
as  organisms  are  frequently  dead  there; 
but  in  order  to  obtain  exact  results,  cul- 
tures should  be  taken  by  scraping  a  swab 
over  the  infected  tissue  surface  so  as  to 
get  organisms  from  the  tissues.  The  cer- 
vix should  be  exposed  by  a  bivalve  specu- 
lum and  a  swab  passed  into  the  os  uteri 
and  rubbed  over  the  endometrium.  The 
material  of  the  swab  is  seeded  over  the 
blood  agar  and  some  isolated  colonies  are 
usuall}^  produced  by  this  method.  Within 
24  to  48  hours  the  gonococci,  if  present, 
will  appear  as  small,  bluish-gray,  semi- 
transparent  colonies,  from  0.5  to  1.5  mm. 
in  diameter.  It  is  a  very  characteristic 
growth  on  blood  agar.  This  method  and 
the  better  knowledge  of  the  cultivation  of 
the  gonococcus  has  rendered  most  of  the 
bacteriological  work  done  upon  the  lochia 
of  puerperal  infection  of  no  value  as  far 
as  the  gonococcus  is  concerned,  and  for 
that  reason  of  very  much  less  value  than 
we  formerly  placed  in  it.  It  will  have  to 
be  most  worked  over  to  include  considera- 
tion of  the  gonococcus  and  anaerobic  or- 
ganisms. 

The  constant  question  among  physicians 
is  why  in  the  last  twenty  years  the  per- 
centage of  puerperal  infection  has  not  de- 
creased and  why  there  is  not  greater  free- 
dom from  it.  The  reason  is  the  preva- 
lence of  gonococcus  vaginal  infection,  its 
chronicity  and  resistance  to  treatment.  It 
shows  few  signs  of  inflammation  and  in 
the  puerperium  lights   up   to  cause  fever, 

^Gurd:  Jour,  of  Med.  Research,  Aug.,  1910; 
Am.  Jour,  of  Med.  Sciences,  Dec,  1908. 


chills,  salpingitis  and  often  death.  When 
the  bacteriology  of  the  puerperal  lochia  is 
studied  in  the  light  of  newer  knowledge, 
it  will  be  known  how  much  puerperal  in- 
fection is  due  to  this  organism  and  how 
many  times  it  has  been  overlooked. 

In  our  17  cases,  previously  reported,  or- 
ganisms were  seldom  found  before  the 
fifth  day  and  they  were  easier  to  identify 
as  the  time  went  on.  Streptococci  were  as- 
sociated with  two  cases,  one  of  which  died 
and  colon  bacillus  with  one  case.  Eight 
cases  had  fever  above  101°  F.  and  twelve 
above  100°  F.  The  fever  lasted  on  the  av- 
erage four  days.  Nine  of  the  seventeen 
had  symptoms  of  abdominal  pain  which  was 
of  the  character  of  pelvic  irritation  due 
to  salpingitis  and  was  believed  to  be  an 
extension  of  the  disease  to  the  tubes.  One 
case  died  from  rupture  of  a  gonococcus 
pus  tube  and  associated  streptococcus  in- 
fection. 

Gurd,  in  his  series  of  five  cases,  has  re- 
ported a  somewhat  similar  case  of  death 
from  gonococcus  and  streptococcus  infec- 
tion. The  association  is  not  uncommon  and 
is  apparently  very  dangerous,  as  it  seems 
to  increase  the  virulence  of  both  organisms. 
In  Gurd's  four  other  cases  of  pure  gono- 
coccus infection,  there  were  chills,  marked 
rises  of  temperature  and  the  other  signs 
of  severe  puerperal  infection,  Mayer^  also 
reported  six  cases  with  high  fever,  severe 
general  infection  with  chills,  so  as  to  give 
the  clinical  picture  of  a  septic  condition. 

These  reports  go  to  show  what  we  main- 
tained in  1905  that  puerperal  gonococcus 
infection  is  often  as  severe  as  infection  with 
the  other  pyogenic  organisms  and  that  this 
organism  is  frequently  overlooked  in  the 
study  of  puerperal   infection.      As  an  ex- 

^Mayer:  Monatschrift  f.  Gynaekol.  and 
Geburtsh,  June,  1906. 


Page  Thirty-eight 


ample  of  the  severity  which  pure  gonococ- 
cus  puerperal  infection  may  attain,  I  would 
add  the  report  of  a  case  where  the  death 
occurred  from  puerperal  infection  with  the 
gonococcus  as  the  sole  infecting  organism. 

CASE      OF      GOXOCOCCUS      PUERPEBAL      INFECTION  — 
DEATH. 

J.  B.,  aged  25,  Primipara.  Full  term;  four 
hours  in  labor;  delivery  normal.  Vertex 
R.  O.  A.  Baby  weigbed  6  lbs.  8  oz.,  and  weight 
at  discharge  was  6  lbs.  It  was  fed  artificial 
after  the  fourth  day,  as  the  danger  to  the  child 
from  toxins  in  the  mother's  milk  was  recog- 
nized. There  was  pain,  rigidity,  masses  in  the 
pelvis  and  a  clinical  picture  of  peritonitis  on 
the  seventh  day.  The  lochia  became  purulent 
and  creamy.  Gonococcus  was  isolated  in  pure 
culture  from  the  uterine  lochia  and  on  smear. 
A  normal  saline  douche  was  given  on  the  sixth 
day  and  a  rise  of  temperature  followed.  Death 
occurred  on  the  ninth  day,  as  may  be  seen  from 
the  chart. 

Autopsy  showed  bilateral  pyosalpinx,  peri- 
tonitis with  pockets  of  pus  all  over  the  abdomen 
with  marked  evidence  of  repair.  Gonococcus 
purulent  endometritis.  The  gonococcus  wa^ 
the  only  organism  isolated  from  the  pus  and 
was  grown  out  in  pure  culture. 

This  case  is  an  example  of  what  severe 
infection  may  result  from  the  gonococcus 
in  the  puerperium. 

While  these  cases  are  severe  and  show 
the  possibility  of  severe  grades  of  infection 
with  this  organism,  the  usual  course  of  the 
disease  is  not  of  this  severity,  any  more 
than  the  usual  course  of  streptococcus  puer- 
peral infection  is  of  this  degree  of  severity. 
Gonococcus  puerperal  infection  usually 
runs  a  milder  course  with  a  comparatively 
low  grade  of  fever.  The  most  characteris- 
tic thing  in  this  infection  is  the  tendency 
to  result  in  purulent  endometritis  with  a 
purulent  flow  from  the  uterus  following  the 
cessation  of  the  bloody  lochia  and  the 
tendency  of  the  disease  to  extend  upward 
to  involve  the  tubes  in  gonococcus  salpin- 
gitis. For  this  reason,  the  after-efifects  of 
gonococcus  infection  are  much  more  se- 
vere than  streptococcus  puerperal  infection  ; 
for  after  a  patient  recovers  from  strepto- 
coccus infection,  all  adhesions  vanish  and 


all  evidences  of  inflammatory  remains  dis- 
appear. But  with  gonococcus  infection  the 
tendency  is  toward  thickening  of  the  walls 
of  the  tubes,  parametritis,  pelvic  perito- 
nitis and  other  marked  evidences  of  repair 
of  tissue. 

The  alteration  of  the  red  lochia  into  the 
creamy  purulent  discharge  is  another  evi- 
dence of  the  extension  of  this  organism 
along  the  mucous  membrane  of  the  genital 
canal.  This  is  its  usual  way  of  progression, 
although  it  may  on  occasion  penetrate  the 
uterine  muscle  as  occurred  in  one  of  our 
cases.  Numerous  gonococci  occupied  spaces 
between  the  superficial  epithelial  cells  and 
the  intracellular  connective  tissue  and  even 
down  into  the  musculature.  This  occurs 
only  occasionally  in  the  softened  puerperal 
uterus. 

One  interesting  phenomenon  of  gono- 
coccus puerperal  infection  was  first  drawn 
attention  to  by  Stone^  and  myself  in  1905 
and  was  confirmed  by  Mayer^  in  June,  1906, 
and  Lobenstine  and  Harrar^  in  December, 
1906.  We  found  that  the  majority  of 
breast-fed  babies  showed  evidences  of  dis- 
turbed nutrition  and  intestinal  disturbance. 
This  was  shown  by  green  stools  and  a 
progressive  loss  of  weight.  The  marked 
difference  betwen  the  nutrition  of  these 
babies  and  of  those  nursed  by  non-infected 
women  was  most  striking  and  transference 
in  two  instances  to  breasts  of  non-infected 
women  was  followed  by  a  rapid  improve- 
ment. The  initial  loss  of  weight  was  greater 
and  it  was  recovered  much  more  slowly. 
They  were  more  subjected  to  rises  of  tem- 
perature.     One-third   of   the   babies   died, 

^Stone  and  McDonald:  Surgery,  Gyn.  and 
Obst.,  Dec,  1905. 

^Mayer:  Monatsschrift  f.  G.  &  G.,  1906,  XXIV, 
62. 

^Lobenstine  and  Harrar:  BuU.  I/jfing-In  Hosp, 
Dec,  1906. 


Page  Thirty-nine 


counting  in  the  cases  of  premature  labor. 
Of  Mayer's  cases,  one-third  of  the  babies 
succumbed  in  the  first  week  of  life  and  the 
others  were  weak  and  their  nutrition  dis- 
turbed. Lobenstine  and  Harrar,  in  a  study 
of  50  babies  of  gonorrheal  mothers  amply 
confirm  our  statement. 

As  a  result  of  these  observations  it  may 
be  seen  that  the  effect  of  gonococcus  in- 
fection extends  to  the  second  generation  in 
a  way  not  heretofore  recognized,  and  for 
these  reasons  it  is  inadvisable  to  allow  a 
mother  with  gonococcus  puerperal  infec- 
tion to  nurse  her  child,  at  least  until  the 
effects  of  the  infection  have  passed  off. 

The  treatment  of  this  form  of  puerperal 
infection  must  be  largely  that  of  preven- 
tion. The  specific  vaginitis  is  always 
present  before  labor  and  appropriate 
measures  should  be  taken  against  it.  This 
is  best  done  by  douches  before  labor.  The 
value  of  douches  before  labor  in  preventing 
puerperal  infection  must  be  studied  anew. 
They  were  formerly  thought  to  be  worth- 
less and  bad,  because  the  numbers  of  or- 
ganisms increased  after  douching.  This 
was  with  bichloride  of  mercury  and  forma- 
lin, but  it  has  been  proved  that,  in  aqueous 
solutions,  these  antiseptics  are  useless  in  the 
presence  of  organic  tissue,  such  as  skin, 
mucous  membrane,  blood  serum,  pus,  etc. 
For  this  reason,  instead  of  being  antisep- 
tics, they  were  only  irritants.  But  with  the 
advent  of  new  efficient  coal  tar  derivative 
germicides  this  is  not  true. 

Burckhardt  and  Kolb,^  for  example,  from 

V.  Herff's  clinic,  in  two  series  of  700  and 

400  cases,  found  that  the  morbidity  in  the 

douched   and   undouched   was   in  the  first 

series  6.5  per  cent,  douched  to  8.6  per  cent. 

undouched,  and  "j-y  per  cent,   douched   to 

^Burckhardt  and  Kolb,  Zeits.  f.  G.  u.  G. 
LXVII,  1. 


10.5  per  cent,  undouched  in  the  second 
series.  They  used  a  halogen  compound  of 
kresol,  known  as  chlor-meta-kresol.  It  is 
said  to  be  powerfully  germicidal,  t©  be  only 
slightly  affected  by  the  presence  of  albu- 
minous fluids  and  to  be  perfectly  harmless 
to  the  mucosa  of  the  vagina.  It  is  non- 
toxic, and  they  speak  highly  of  its  restrain- 
ing influence  on  the  growth  of  organisms. 

This  substance  as  a  douche  before  labor 
for  gonococcus  infection  is  the  best  form 
of  treatment  which  can  be  given.  Any  ef- 
fort at  local  treatment  can  only  end  in  uter- 
ine irritation  and  possible  premature  labor. 

Labor  should  be  conducted  with  as  little 
traumatism  and  as  few  examinations  as 
possible.  After  the  infection  is  established, 
the  treatment  must  consist  of  douches  of 
the  above  mentioned  germicide  and  as  little 
operative  manipulation  as  possible.  Rest  in 
bed  for  longer  than  the  usual  time  should 
be  advised.  Local  treatment  and  operation 
for  local  pus  collection  must  be  done  on  di- 
agnosis of  the  abscess.  But  the  greatest 
hope  is  in  the  prevention  of  the  condition. 

CHAPTER  X. 

BLADDER  TROUBLES  IN  PREGNANCY 

—A  CYSTOSCOPIC  STUDY  BASED 

ON  54  GASES. 

The  proximity  and  intimate  association 
of  the  bladder  with  the  uterus  involves  it  in 
any  changes  which  may  take  place  in  this 
organ.  The  increase  in  size  and  blood 
supply  of  the  uterus  in  pregnancy  causes 
alterations  to  appear  in  the  bladder.  This 
in  the  very  early  stages  of  pregnancy 
amounts  to  only  a  congestion  of  the  tri- 
gone. Apart  from  cases  of  cystitis  twelve 
cases  of  normal  early  pregnancy  without 
any  bladder  disturbance  were  examined  to 


Page  Forty 


ascertain  if  there  were  any  characteristic 
or  distinct  changes  which  might  aid  the 
diagnosis  of  early  pregnancy.  These 
cases  were  examined  at  varying  periods 
and  most  of  them  repeatedly  during  the 
early  weeks  of  pregnancy.  The  conges- 
tion usually  appeared  very  early  in  preg- 
nancy and  was  noticeable  over  the  trigone 
about  the  sixth  week.  It  began  at  the 
outlet  of  the  urethra,  the  bladder  orifice, 
and  spread  upward  toward  the  ureteral 
orifices.  The  spread  of  the  congestion  fol- 
lowed the  course  of  the  radiating  blood 
vessels. 

This  hyperemia  had  a  very  distinct  ef- 
fect upon  any  previous  inflammation  of  the 
bladder  or  trigone.  If  there  had  been  previ- 
ous symptoms  of  trigonitis,  it  was  com- 
mon to  have  a  recrudescence  of  these  symp- 
toms to  frequency  of  urination  and  pain 
aifter  the  addition  of  the  congestion  of 
pregnancy.  This  hyperemia  is  more  marked 
in  pregnancy  with  retroverted  uterus,  be- 
cause in  such  conditions  of  retroversion, 
there  is  a  greater  amount  of  congestion  in 
the  early  part  of  pregnancy,  than  there  is 
with  pregnancy  and  anteversion.  With  the 
advance  of  pregnancy  the  congestion  of  the 
bladder  mucosa  becomes  more  and  more 
marked.  The  membrane  loses  its  usual 
pink-white,  shell-like  appearance  and  be- 
comes a  cream-yellow,  and  also  gains  the 
appearance  of  greater  thickness.  It  is  the 
difference  between  white  China  silk  and 
cream-colored  velvet.  The  bladder  lining 
becomes  more  velvety  and  softer.  There 
is  apparently  a  greater  increase  in  edema 
and  a  greater  increase  in  the  lymphatic  tis- 
sue of  the  bladder. 

This  edema  is  usually  most  marked  about 
the  neck  of  the  bladder.  It  involves  the 
orifices  of   the  ureters  also,   so  that  they 


become  more  thickened  and  more  erect. 
This  thickening  of  the  ureters  is  so  notice- 
able that  in  pregnancy  they  can  usually 
be  palpated  from  the  vagina.  This  thick- 
ening of  the  ureters  may  cause  an  obstruc- 
tion of  the  urinary  flow;  although,  if  there 
has  been  previous  inflammation  of  the  tri- 
gone, the  ureter  is  more  commonly  rigidly 
patent — the  so-called  "golf-hole"  orifice. 

This  condition  of  patulous  ureteral  ori- 
fice is  apparently  due  to  the  stretching  of 
the  intra-ureteral  ligament  by  the  growing 
cervix  of  the  pregnant  uterus.  The  en- 
larged cervix  presses  upon  the  bladder  to 
which  it  is  intimately  related  and  causes 
alteration  in  the  structure  of  the  ureteral 
orifice  by  the  pull  which  is  caused.  The 
orifice  from  being  an  elevated  papilla  be- 
comes flattened,  stretched  and  elongated. 
This  condition,  as  described,  was  cysto- 
scopically  traced  in  one  case  who  became 
pregnant  while  under  treatment  for  cystitis. 

The  orifice  on  the  right  side  more  fre- 
quently becomes  patulous,  than  that  on  the 
left.  This  may  be  due  to  the  fact  that  the 
bladder,  particularly  in  the  later  months 
of  pregnancy,  lies  more  upon  the  right  side. 
This  may  be  explained  by  the  rotation  of 
the  uterus  to  the  right  and  not  by  the  posi- 
tion of  the  child. 

The  "golf-hole,"  or  patulous  ureter,  is 
usually  an  association  of  previous  bladder 
inflammation  and  is  in  the  specimens  I 
have  obtained  at  autopsy  usually  sur- 
rounded by  round-celled  infiltration,  plasma 
cells  and  inflammatory  edema. 

In  addition  to  changes  in  the  trigone, 
the  whole  bladder  wall  is  altered  in  appear- 
ance and  texture.  There  is  an  apparent  in- 
crease in  the  epithelium  and  large  quanti- 
ties of  epithelial  cells  are  cast  oft'  in  the 
urine.     This  is  one  of  the  chief  character- 


Page  Forty-one 


istics  of  the  bladder  in  pregnancy;  the 
shedding  of  the  epithehum  and  the  pro- 
Hferation  of  new  cells. 

In  six  cases  of  pregnant  bladders,  ob- 
tained at  autopsy,  the  general  picture  was 
that  to  be  expected  from  the  cystoscopic 
examination.  The  muscle  fibers  had  hyper- 
trophied  and  this  increase  was  most 
noticed  in  the  external  muscular  layer  and 
more  particularly  in  the  lower  part  of  the 
ureter,  where  it  lay  with  the  bladder  wah 
itself.  This  was  frequently  associated  with 
small  round-celled  infiltration,  plasma  cells 
and  edema.  The  epithelium  showed  consid- 
erable active  proliferation  with  the  appear- 
ance of  many  karyokinetic  separations  of 
the  nuclei,  and  there  were  a  considerable 
number  of  degenerating  or  disintegrating 
superficial  epithelial  cells  with  pale  stain- 
ing nuclei. 

In  the  later  stages  of  pregnancy,  dis- 
placement of  the  bladder  is  the  common 
event.  This  displacement  is  almost  con- 
stantly to  the  right  and  apparently,  from 
Martin's  roentgenograms,^  is  due  to  the 
torsion  of  the  uterus  upon  its  longitudinal 
axis  from  left  to  right.  The  extent  of  the 
displacement  is  not  influenced  by  labor,  but 
by  the  size  of  the  presenting  part  and  by 
the  thickness  of  the  tissues  around  the  blad- 
der. The  trigone  and  the  upper  part  of 
the  urethra  can  sometimes  accompany  the 
bladder  in  its  displacement. 

This  displacement  increases  the  conges- 
tion and  edema  in  the  pregnant  bladder  and 
there  are  sometimes  found  ecchymoses 
around  the  neck  of  the  bladder. 

These  alterations  in  the  bladder  of  the 
pregnant    cause    some    differences    in    the 

^Martin:  Arch.  f.  Gynaekologie,  1909, 
IXXXVIII,  2,  Zentraim.  f.  Gynaek,  1909 


type  of  inflammation  which  may  occur,  and 
in  its  treatment.  There  exists  in  preg- 
nancy a,  type  of  inflammation  which  is 
marked  by  fairly  generalized  e^^ema  and 
hyperemia.  Speaking  generally,  inflamma- 
tion is  much  less  apt  not  to  be  confined  to 
the  trigone,  than  in  the  non-pregnant,  and 
is  more  apt  to  spread  in  the  pregnant  blad- 
der over  the  rest  of  the  bladder  wall.  The 
inflammation  is  more  apt  to  be  general  and 
uniform.  There  is  usually  marked  des- 
quamation and  exfoliation  of  epithelium 
and  pus.  The  amount  of  pus  is  greater  in 
bladder  inflammations  in  pregnancy,  than 
in  the  non-pregnant.  The  exfoliated  cells 
and  shreds  cling  to  the  bladder  wall  like 
small  tags.  The  picture  is  that  of  an  acute 
cystitis  with  much  edema  and  marked  con- 
gestion. The  mucosa  is  markedly  swollen, 
softened  and  boggy.  The  amount  of  pus 
excreted  is  great.  The  clinical  picture  is 
sufficiently  characteristic  to  be  called  cys- 
titis of  pregnancy. 

There  is  apt  to  be  a  recurrence  of  this 
inflammation  with  a  succeeding  pregnancy, 
as  was  seen  in  two  cases  that  were  ex- 
amined in  succeeding  pregnancies  v/ith  the 
same-  picture  in  each  pregnancy.  In  one 
case  there  was  hemorrhage  due  to  the  ooz- 
ing of  the  blood  from  an  engorged  vari- 
cose vein.  This  recurred  in  each  preg- 
nancy, but  was  stopped  by  injections  over 
the  area  of  solutions  of  suprarenin.  In  one 
pregnancy  the  oozing  continued  until  term 
after  which  there  was  a  rapid  recovery. 

In  both  of  the  cases,  in  the  first  preg- 
nancy, there  was  on  account  of  a  right- 
sided  pain  and  large  quantities  of  pus,  sus- 
pected pyelitis  of  pregnancy.  However, 
catheterization  of  the  ureter  showed  clear 
urine  and  the  cystoscopic  picture  explained 
the  large  amounts  of  pus. 


Page  Forty-two 


Fever,  usually  of  a  mild  degree,  may  be 
present  in  cystitis  of  pregnancy.  It  is  much 
more  common,  than  in  cystitis  in  the  non- 
pregnant. 

These  alterations  in  the  bladder  and  the 
different  character  of  the  inflammation  ex- 
plain the  frequency  of  involvement  of  the 
kidney  in  pyelitis  of  pregnancy.  The  ure- 
ter loses  its  valve-like  action  and  allows 
urine  to  regurgitate  into  the  kidney  pel- 
vis. It  may  be  that  the  displacement  of  the 
bladder  to  the  right  side  may  explain  the 
greater  frequency  of  involvement  of  the 
right  kidney.  An  evidence  of  the  fact  that 
ascending  ureteral  infection  is  the  com- 
mon course  in  pyelitis  is  that  the  infecting 
organism  is  almost  always  the  colon  ba- 
cillus, and  this  is  an  organism  rarely  found 
in  the  blood. 

The  diagnosis  of  pyelitis  of  pregnancy 
should  depend  upon  the  cystoscopic  exami- 
nation and  ureteral  catheterization.  It 
may  be  perfectly  simulated  by  cystitis  of 
pregnancy  with  fever,  pus  in  the  urine  and 
right-sided  pain,  as  may  be  seen  from  cases 
previously  reported.  In  these,  without 
ureteral  catheterization,  the  diagnosis  would 
have  been  mistaken  and  the  wrong  treat- 
ment would  have  been  instituted. 

The  cystoscopic  examination  of  the  54 
cases  of  pregnancy  shows  that  an  old, 
latent  trigonitis  may  often  light  up  again 
with  pregnancy  and  become  general.  A 
number  of  cases  were  followed  through- 
out pregnancy  and  there  was  apparently  no 
increase  of  this  congestion  throughout. 

Cystitis  in  the  pregnant  differs  a  little 
in  its  treatment  from  cystitis  in  the  non- 
pregnant. The  occurrence  of  ulcers  is  not 
so  common.  When  they  do  occur,  they 
should  not  be  treated  locally,  until  the  sur- 
rounding bladder  has  recovered.  Treat- 
ment in  general  is  better  made  by  medi- 

Page  Forty-three 


cated  solutions,  such  as  quinine  bisulphate 
1  :2,000,  boric  acid,  nitrate  of  silver  1 :30,- 
000  and  mild  astringents.  Injection  of 
small  amounts  of  strong  silver  salts  is  not 
to  be  advised.  The  patients  are  more  in- 
fluenced by  rest  and  plenty  of  water,  than 
are  the  non-pregnant.  Hexamethylen- 
tetramin  should  be  used  with  care  on  ac- 
count of  its  tendency  to  irritate  the  kid- 
neys and,  when  used,  should  be  combined 
with  sodium  benzoate.  The  kidney  of 
pregnancy  is  usually  the  seat  of  a  fatty 
degeneration  and  does  not  have  as  much  re- 
serve as  the  non-pregnant. 

In  the  treatment,  the  absence  of  trauma 
and  injury  is  of  greatest  importance  on  ac- 
count of  the  softened  and  most  susceptible 
condition  of  the  bladder  wall.  For  this 
reason,  the  utmost  care  must  be  employed 
in  using  the  catheter^  as  has  been  pointed 
out  in  another  paper. 


CHAPTER  XL 

THE  DURATION  OF  PREGNANCY. 

The  duration  of  human  pregnancy  is  one 
of  the  unsettled  problems  of  medicine  and 
must  remain  so,  because  pregnancy  has  no 
fixed  term,  but  varies  normally  within  wide 
limits.  It  is  a  difficult  matter  to  study  be- 
cause of  the  impossibility  of  being  sure  of 
the  time  of  conception  even  although  there 
is  only  one  coitus.  The  spermatozoa  may 
live  for  five  days  in  the  vagina  and  con- 
ception may  take  place  some  time  after 
coitus.  It  is  also  difficult  to  be  sure  that 
only  one  intercourse  has  taken  place,  even 
although  the  masculine  side  of  the  ques- 
tion is  without  debate, 

^  MacDonald :  Pyelitis  in  Pregnancy,  Am. 
Med.,  Dec.  1910. 


The  subject  is  one  which  sometimes  gives 
rise  to  interesting  medico-legal  problems. 
The  most  famous  of  these  is  the  Gardner 
peerage  case,  where  the  husband,  a  sol- 
dier, was  absent  from  his  wife  302  days  be- 
fore birth  of  a  child  to  his  wife.  A  more 
recent  divorce  case  brought  up  the  ques- 
tion whether  a  fully  developed  baby  born 
247  days  after  the  return  of  the  wife  to 
the  husband  could  be  the  offspring  of  the 
husband. 

A  case  recently  came  under  my  notice 
as  medical  expert.  The  girl  was  married 
by  a  young  man,  because,  she  said,  he  had 
impregnated  her.  This  was  said  to  have 
occurred  in  September.  She  stated  that 
her  last  menstruation  was  September  23d. 
The  young  man  was  urged  to  annul  the 
marriage.  Examination  showed  a  pregnant 
uterus  whose  fundus  was  24^^  cm.  high 
above  the  symphysis,  measured  according 
to  my  rule.  This  gave  the  duration  of  preg- 
nancy as  (24^  -^  3/^)  7  lunar  months  and 
dated  the  pregnancy  back  to  July  i8th.  At 
this  time  the  girl  was  not  in  this  country. 
Careful  questioning  brought  out  the  truth 
that  about  that  time  she  was  in  a  hotel 
abroad,  had  had  relations  with  another 
man  and  had  shortly  afterwards  missed  her 
menstruation  and  on  her  return  had  looked 
around  for  an  easy  victim.  Had  it  not 
been  that  a  definite  statement,  as  based  on 
the  rule  of  duration  of  pregnancy  was 
made  the  confession  would  not  have  been 
obtained. 

As  the  size  of  the  child  varies,  so  may 
the  duration  of  pregnancy.  Observations 
upon  cows,  whose  term  of  pregnancy  ap- 
proaches in  duration  that  of  the  human 
animal,  have  shown  that  their  period  of 
gestation  is  by  no  means  a  fixed  term,  but 
varies  from  240  to  321  days.  The  average 
duration  was  285  days  according  to  Tes- 


sier's  researches  which  extended  over  40 
years.  Earl  Spencer's  experiments  in  724 
cases  corroborate  those  of  Tessier.  While 
the  variation  of  the  duration  of  f^;egnancy 
in  cows  is  no  evidence  of  a  similar 
variation  in  the  human  animal,  it  is  at 
least  suggestive  that  a  similar  variation 
does  occur  in  pregnancy  in  women.  The 
range  of  variation  is  about  what  our  re- 
searches into  human  pregnancy  lead  us  to 
expect. 

There  is  no  doubt  that  pregnancy  in 
women  may  be  prolonged  in  a  certain  per- 
centage of  cases  and  several  instances  of 
abnormally  long  pregnancy  have  been  re- 
ported. WinckeP  has  collected  20  cases 
which  he  has  discussed  in  detail,  and  has 
accepted  6  cases  as  authentically  proved 
prolonged  pregnancy  of  310,  311,  312,  324 
and  336  days,  with  children  weighing  from 
5770  to  7470  grams.  Nine  of  the  remain- 
ing cases  he  rejects  as  not  proved,  and  five 
were  not  completely  satisfactory.  Many 
other  isolated  cases  have  been  reported, 
such  as  those  of  Allen^  and  many  others. 

While  it  is  difficult  in  many  cases  to 
estimate  exactly  the  probable  time  of  con- 
ception, it  is  conceded  by  obstetricians  gen- 
erally that  prolongation  of  pregnancy  does 
occur,  and  that  the  children  of  such  preg- 
nancies are  remarkable  for  their  large  size. 
It  is  also  believed  that  a  proportion  of 
overweight  children  are  carried  for  more 
than  the  average  time  of  pregnancy.  While 
admitting  that  isolated  observations  prove 
nothing  in  this  connection,  it  is  evident 
that  the  average  duration  of  many  hun- 
dred cases  weighing  4000  grams,  and  over, 
must  have  considerable  force.  Winckel  has 
collected  245  cases  of  this  great  weight 
and   estimated   the  duration  of  pregnancy 

'^Leyden's  Deutsche  EliniTc,  IX,  5  to  10. 
^Amer.  Journ.  Obst.,  1907,  IV,  4. 


Page  Forty-four 


as   follows,   as   to   the  time   after  the  last 
menstruation : 


Liration  of  Pregnancy 

After  last 

in  days. 

Menstruation. 

241  to  260 

3.7  per  cent. 

261  to  270 

6.1 

271  to  280 

18.3         " 

281  to  290 

38.0 

291  to  300 

18.8 

301  to  310 

8.5         " 

311  to  336 

6.6 

This  collection  shows  that  it  is  not  an 
isolated  occurrence  that  heavyweight  chil- 
dren are  carried  beyond  the  ordinary  term 
of  pregnancy;  but  it  is  a  fairly  definite 
proof  that  children  are  often  overweight, 
because  they  are  carried  for  longer  than  the 
ordinary  term.  While  it  is  true  that  large 
infants  may  be  the  result  of  short  preg- 
nancies, as  was  the  case  in  3.7  per  cent,  of 
these  cases,  it  is  more  common  that  heavy 
children  are  the  result  of  pregnancies 
longer  than  the  average  280  days,  as  was 
the  result  in  71.8  per  cent,  of  this  series. 

In  31  of  the  larger  babies  with  an  aver- 
age length  of  53.8  cm.  and  an  average 
vv^eight  of  4276  grams,  the  prolongation  of 
the  gestation  period  was  31  days,  counting 
from  the  last  menstrual  period.  The  aver- 
age prolongation  of  the  gestation  in  in- 
fants weighing  4000  grams,  or  slightly  less 
than  the  preceding,  was  8.22  days,  reckon- 
ing in  the  same  way  from  the  last  men- 
struation. Thus,  also,  in  children  weigh- 
ing 4000  grams  it  was  found  that  30,  or 
12.2  per  cent,  had  had  a  gestation  period 
of  longer  than  302  days,  the  legally  de- 
termined duration  of  pregnancy  in  Ger- 
many. 

Blau  and  Christofoletti^  also  have  col- 
lected the  cases  of  large  children  from  68,- 
032  births   in   the   clinics   of   Schauta   and 

^  Monats.  f.  Gehurtsh.  u.  Oyn.,  1904. 


Chrobak  for  the  years  1892  to  1901,  in  or- 
der to  determine  the  correlation  of  large 
children  and  protracted  gestation.  Among 
1778  children  weighing  more  than  4,000 
grams,  the  pregnancy  lasted  more  than  300 
days  in  150  cases,  and  more  than  302  days 
in   135  cases. 

This  seems,  therefore,  to  be  conclusive 
proof  that  pregnancy  may  persist  for 
longer  than  280  days  and  that,  when  it  is 
prolonged  over  term,  the  resulting  child 
is  commonly  of  large  size.  These  cases 
cited  were  clinic  cases,  where  conditions 
were  not  favorable  to  large  children,  as  re- 
pose favors  the  increase  in  weight  of  the 
child.  Rest,  as  has  been  proved  by  Pin- 
ard^,  is  a  factor  which  may  distinctly  pro- 
long the  pregnancy.  This  may  explain  the 
difference  between  gestation  in  summer 
(277.2  days)  and  winter  (279.5  days)  or 
between  married  (282.4  days)  and  unmar- 
ried (278.2  days),  as  has  been  shown  by 
Pinard^  This  influence  of  quiet  and  rest 
will  also  explain  the  larger  number  of 
heavy  children  found  in  private  practice, 
as  the  luxury  of  a  home  influences  the 
weight  of  the  fetus.  Letourier^  has  shown 
that  women  who  have  fatiguing  w^ork  to 
do  have  children  lighter  in  weight  than 
those  who  are  able  to  rest  during  their 
gestation.  He  found  an  average  difference 
of  220  grams  between  these  classes. 

The  type  of  menstruation,  the  sex  of  the 
fetus,  and  heredity  are  all  said  to  have  ef- 
fect upon  the  size  of  the  fetus  and  the 
duration  of  pregnancy ;  but  none  are  proved 
to  have  any  influence. 

On  the  other  hand,  constitution  and 
habitus   do   seem  to  have   an   influence  as 

^  Bictionnaire  de  Physiologie,  1905,  article 
Gestation. 

'  Clinique  Otstetricale,  1899,  51. 

^TJiese  de  Paris,  1897:  De  I'influence  de  la 
profession  de  la  mere  sur  le  poids  de  I'enfant. 


Page  Forty-five 


Issmer^  found  an  average  duration  of 
2/8.6  days  in  robust  women,  and  276.8 
days  in  weak  women.  He  also  states  that 
there  is  an  average  increase  of  weight  of 
the  child  in  each  pregnancy  of  224.5  grams. 
The  first  child  is  the  smallest,  as  a  rule, 
and  each  succeeding  pregnancy  produces  a 
larger  child  up  to  the  ninth. 

Another    artificial    cause    of    prolonged 
pregnancy  is  the  performance  of  the  oper- 


able to  press  the  presenting  part  into  the 
OS  to  bring  about  dilatation.  From  the 
various  reports  it  appears  that  the  pains 
came  on  and  passed  off  again  sev^al  weeks 
before  birth  actually  occurred. 

While  thus  it  may  be  seen  that  many 
factors  affect  the  duration  of  pregnancy, 
Issmer  has  also  estimated  that  the  size  of 
the  fetus  bears  a  relation,  as  a  rule,  to  the 
duration  of  pregnancy,  as  follows : 


Fig.  1. 


ation  of  ventrofixation  of  the  uterus.  A 
number  of  long  pregnancies  with  very 
large  children  have  been  reported  after  this 
operation.  The  most  likely  explanation  is 
that  the  unequal  development  of  the  uterus 
and  the  thinning  of  the  posterior  wall 
causes  the  cervix  to  be  displaced  in  its  re- 
lation to  the  pelvic  axis.  The  early  pains, 
being  weak  from  the  thin  walls,  are  not 
^Arch.  f.  Gyn.,  XXX,  277,  and  XXXV,  310. 


48  cm.  averages 

49  cm. 

50  cm. 

51  cm. 

52  cm. 

53  cm- 

54  cm. 


271.3  days 

278.4 

277.1 

282.5 

283.6 

286.5 

"  290.0 

He  states  that  there  may  be  a  difference 

of  ten  to  eighteen  days  in  the  duration  of 

pregnancy;  but,  basing  his   statements   on 


Page  Forty-six 


the  average  of  his  large  collection  of  cases, 
he  says  that  the  larger  the  child  the  longer 
is  the  pregnancy,  and  that  the  increase  is 
in  the  proportion  of  his  table.  Large  chil- 
dren do  also  occur  in  shorter  pregnancies, 
but  they  are  much  more  infrequent  than 
when  the  pregnancy  is  prolonged. 

These  variations  in  the  duration  of  preg- 
nancy make  it  difficult  to  prognosticate  the 
date  of  labor.  If  the  usual  rule  is  applied 
of  adding  seven  days  and  subtracting  three 
months  from  the  date  of  the  last  menstrua- 
tion, the  estimate  may  be  three  weeks  out 
of  the  way ;  but  basing  it  upon  the  aver- 
age duration  of  pregnancy,  it  is  often  cor- 
rect. However,  conception  may  have  oc- 
curred immediately  before  the  first  missed 
menstruation,  and  so  give  a  factor  of  er- 
ror. 

Since,  however,  the  attempt  to  estimate 
the  duration  of  pregnancy  by  the  number 
of  days  is  inexact,  it  might  be  well  to  at- 
tempt to  estimate  the  duration  of  preg- 
nancy from  the  size  of  the  fetus.  For,  if 
the  fetus  may  be  measured  and  the  aver- 
age size  of  the  fetus  is  known,  the  date  of 
labor  will  be  when  the  fetus  arrives  at 
average  size  in  the  great  majority  of  cases. 

So,  with  the  hope  of  being  able  to  de- 
termine the  date  of  labor,  I  have  evolved 
a  rule  which  is  dependent  upon  the  height 
of  the  fundus  of  the  uterus  above  the 
symphysis.  The  height  of  the  fundus  is 
dependent  upon  the  occipitococcygeal  meas- 
urement of  the  child,  and  this  varies  in  di- 
rect proportion  to  the  weight  of  the  child, 
as  does  the  length.  The  details  of  this 
proportion  have  been  worked  out  in  a  pre- 
vious paper^. 

The  rule  is  as  follows :  The  duration  of 
pregnancy  in  lunar  months  is  equal  to  the 

^Mensuration  of  the  Child  in  the  Uterus,  Jour. 
Amer.  Med.  Ass'n.,  December  15,  1906. 


height  of  the  uterus  in  centimeters  divided 
by  3.5.  It  depends  upon  the  more  or  less 
regular  growth  of  the  uterus  of  3.5  cm. 
each  month  of  four  weeks,  and  is  very  ex- 
act after  the  sixth  month.  The  measurement 
is  taken  with  the  patient  lying  flat  (see 
figure),  and  one  end  of  the  tape  is  placed 
at  the  upper  border  of  the  symphysis, 
while  the  other  is  held  by  the  thumb 
into  the  palm  of  the  hand.  The  fingers 
of  the  upper  hand  are  held  at  right 
angles  to  the  fundus  of  the  uterus, 
and  the  tape  follows  the  contour  of  the 
uterus  save  at  the  last  dip,  as  is  shown  in 
the  illustration.  Multiparae  with  lax  ab- 
dominal walls  and  thin  uteri  should  be  sup- 
ported at  the  side,  so  as  to  bring  the  oc- 
cipitococcygeal axis  of  the  pelvis  into  the 
long  axis  of  the  mother's  body. 

This  method  gives  satisfactory  results 
and  is  the  most  exact  means  of  estimation 
of  the  duration  of  pregnancy.  It  is  strictly 
an  estimation  of  the  size  of  the  fetus;  for 
when  the  uterus  arrives  at  the  height  of 
35  cm.,  or  full  term  (35^3.5^10  lunar 
months),  the  fetus  is  of  a  weight  of  3,300 
grams,  or  average  size,  as  is  shown  by  the 
measurements  in  my  former  paper.  Thus, 
an  average-sized  baby  usually  comes  at  the 
average  period  of  pregnancy — hence  the 
rule. 

i\fter  the  sixth  month  this  rule  is  extra- 
ordinarily exact,  and  is  most  useful  in  de- 
termining the  date  of  labor  and  the  size  of 
the  fetus,  when  the  date  of  the  last  men- 
struation has  been  forgotten.  It  has  been  in 
use  in  my  hands  since  1904,  and  I  have  had 
good  reports  of  it  from  many  obstetricians, 
including  some  of  my  German  confreres. 
Hamilton  has  reported  it  to  me  to  be  of 
great  use  in  asylum  practice  in  insane  preg- 
nant women  who  are  not  able  to  give  a 
connected  history  of  menstruation. 


Page  Forty-seven 


II,I.USTRATIOiSr. 

Author's  Rule:  The  duration  of  the 
pregnancy  in  lunar  months  equals  the 
height  of  the  uterus  in  centimeters  divided 

by  3-5- 

It  may  be  said  that  35  cm.  is  the  usual 
height  of  the  uterus  at  full  term  with  a 
fetus  of  3,300  grams.  For  every  centimeter 
of  height  above  this  measurement  approxi- 
mately 200  grams  should  be  added  to  the 
weight  of  the  fetus.  Thus,  a  uterus  meas- 
uring 37  cm.  would  contain  a  fetus  weigh- 
^^S  3^700  grams.  The  measurements  are 
more  exact  below  35  cm.,  than  above  that 
height. 

The  so-called  "sinking"  of  the  fetus  in 
the  last  two  weeks  of  pregnancy  causes  but 
little  error  in  the  measurement,  as  the  head, 
when  the  patient  is  recumbent,  rides  up- 
ward on  the  pelvic  bones  and  the  sinking 
is  not  a  factor.  "Sinking"  in  my  experi- 
ence is  not  common  in  primiparae,  and  its 
supposed  presence  is  often  due  to  the 
stretching  of  the  abdominal  muscles  and 
not  to  descent  of  the  head  into  the  pelvis. 
The  fundus  thus  comes  lower  in  the  erect 
position,  and  no  diminution  of  the  fundal 
height  is  noted  in  the  recumbent.  This  is 
well  shown  in  Hirst's  photographs  of 
women  at  various  periods  of  pregnancy. 
"Sinking"  does,  however,  in  multiparae 
sometimes  complicate  the  measurement, 
but  not  often.  Hydramnios  also  causes  but 
small  error,  as  the  excess  of  liquid  does 
not  affect  the  fundus,  but  the  body  of  the 
uterus,  leaving  the  height  of  the  fundus  to 
be  determined  by  the  occipitococcygeal 
measurement  and  the  size  of  the  fetus. 

The  rule  gives  the  most  exact  means  at 
hand  of  prognosticating  the  date  of  labor. 
No  rule  can  be  exact  when  dealing  with 
such  an  uncertain  quantity  as  the  duration 
of  pregnancy,  save  that  in  the  majority  of 


cases  an  average-sized  baby  is  born  at  the 
average  time. 

Thus,  if  the  fundus  measures  26  cm, 
from  the  symphysis,  the  duratios  of  preg- 
nancy is  26  divided  by  3.5  or  7  3-7  lunar 
months,  and  the  patient  has  2  4-7  lunar 
months  to  go  to  term,  or  ten  weeks  and  two 
days. 

This  rule,  combined  with  the  estima- 
tion of  pregnancy  by  reckoning  from  the 
last  menstruation,  gives  a  fairly  exact  de- 
termination of  the  probable  date  of  labor. 

While  the  rule  is  useful  for  the  deter- 
mination of  the  date  of  labor,  it  is  still 
more  useful  for  the  determination  of  the 
size  of  the  fetus,  with  a  view  to  induction 
of  labor  for  contracted  pelvis  or  other 
cause.  When  the  fundal  measurement  is 
at  or  near  35  cm.,  I  never  hesitate  to  induce 
labor  when  indicated,  knowing  that  there 
is  a  fetus  of  the  average  weight  of  about 
3,300  grams  and  capable  of  standing  in- 
strumental delivery  and  not  liable  to  die 
from  prematurity. 

When  used  for  the  purpose  of  estimat- 
ing the  size  of  the  child  in  contracted  pel- 
vic or  other  conditions,  it  should  be  used 
in  conjunction  with  other  methods  of 
measuring  the  head.,  etc. 

CHAPTER  Xn. 

MEASUHING     THE     BABY     BEFORE 
BIRTH. 

General  Considerations. — The  whole 
question  of  prognosis  and  prognostication 
of  any  individual  labor  depends  upon  the 
size  of  the  child.  It  may  be  said,  generally 
speaking,  that  if  a  woman  has  a  small 
child,  she  will  have  an  easy  labor,  an  aver- 
age size  child  an  average  labor,  and  a  large 
child  a  hard  labor. 


Page  Forty-eight 


This  is  particularly  the  case  in  moderate 
degrees  of  contraction  of  the  pelvis. 
Marked  contraction  of  the  pelvis  is  rare; 
moderate  contraction  is  not  uncommon.  In 
moderately  contracted  pelvis  with  a  true 
conjugate  above  8.5  cm.  there  is  85  per 
cent,  of  spontaneous  delivery.  (A  true 
conjugate  of  11  cm.  is  normal).  In  the 
other  15  per  cent.,  the  pelvis  is  obviously 
not  too  small,  but  the  baby  is  too  large.  The 
difference  between  a  six  and  ten-pound 
baby  is  considerable.  The  larger  baby  has 
a  larger  head,  so  that  it  will  not  come 
through  as  small  a  hole.  The  larger  head 
is  firmer,  the  bones  well  ossified,  and  mould- 
ing is  more  difficult.  Apart  from  the  other 
causes  of  difficulty  in  labor  from  large 
babies,  these  are  sufficient.  If  the  babies 
were  small  enough  and  kept  sm.all  enough, 
the  other  15  per  cent,  would  be  born  spon- 
taneously, too. 

The  pelvis  can  be  measured  exactly  and 
an  opinion  formed  of  it  by  examination. 
But  if  a  pelvis  is  moderately  contracted,  it 
may  allow  a  small  or  normal-sized  baby  and 
not  a  large  one.  Who,  when  buying  bul- 
lets for  a  rifle,  would  measure  the  bore  and 
not  the  ball?  Yet,  we  measure  a  pelvis 
carefully  and  do  not  even  try  to  estimate 
the  size  of  the  baby.  For  if  the  size  of  the 
baby  may  be  measured,  induction  of  labor 
may  be  done  at  a  time  when  the  child  is 
viable  and  strong  and  yet  come  through. 
The  normal-sized  babies  do  not  cause 
trouble  in  moderately  contracted  pelves, 
but  the  big  fellows  do.  The  biparietal 
diameter  comes  into  relation  with  the  true 
conjugate  and  in  a  normal  child  this  aver- 
ages 9.25  cm.,  so  that  with  a  true  conjugate 
of  the  same  contraction,  9.25,  the  child 
should  in  the  general  run  of  circumstances 
be  born  spontaneously,  as  they  are  in  85 
Page  Forty-nine 


per  cent,  with  the  rather  greater  contrac- 
tion of  8.5  cm. 

But  the  profession  is  ghost-dancing  after 
that    false    prophet,    Caesarean    section    in 
moderately    contracted    pelvis,     forgetting 
other  less  spectacular  and  less   dangerous 
methods.     It  is  so  easy  to  do  a  Caesarean 
section.     Cut  in,  pull  out  the  child  and  sew 
up.     It   is   the   easiest  kind   of   abdominal 
operation,  yet  the  mortality  in  3,000  col- 
lected cases  in  the  last  twenty  years  is  7 
per  cent.  One  operator,  Davis,^  has  done 
104  with  14  per  cent,  mortality  in  mothers 
and  17  per  cent,  in  children,  one  in  every 
seven  women  died  after  Caesarean  section. 
McPherson^  has  recently  reported  352  cases 
from    the    Lying-In    Hospital     (including 
Davis'  cases)  with  10.7  per  cent,  mortality. 
There    were    187    with    unruptured    mem- 
branes with  10  per  cent,  mortality  and  165 
cases  with  ruptured  membranes  with  11.5 
per  cent  of  deaths.     Fifteen  per  cent,  of 
all   the    children    died.     Caesarean    section 
should  be  confined  to  those  cases  of  con- 
tracted pelvis  that  cannot  possibly  be  de- 
livered in  other  ways.     It  will  always  be 
an  operation  of  considerable  mortality  on 
account  of  the  condition  of  the  uterus,  the 
trauma,  lessened  resistance  of  the  pregnant 
and  the  escape  and  contamination  of  dis- 
charges.      These     conditions     are     funda- 
mental. 

What  is  the  other  side  of  the  picture  ?  In 
941  collected  cases  of  induction  for  con- 
tracted pelvis,  one  mother  died  and  88  per 
cent,  of  the  children  were  saved.  This  is 
somewhat  better  than  210  mothers  dying 
after  3,000  Caesarean  sections  and  96  per 
cent,  of  children  born  alive  with  no  record 
of  those  dying  in  the  puerperium.     Induc- 

^A.  B.  Davis,  Bull.  Lying-in  Hospital,  June, 
1911.     Surgery,  Gyn.  and  O'ost.,  Oct.,  1911. 

^McPherson,  N.  Y.  State  Jour.  Med.,  1913, 
March. 


tion  is  obviously  considerably  safer  for  the 
mother  and  about  the  same  for  babies.^ 

If,  then,  we  can  measure  the  bullet  as 
well  as  the  bore,  better  results  can  be  ob- 
tained. When  we  can  measure  the  baby 
accurately,  Caesarean  section  in  moderately 
contracted  pelves  will  be  unjustifiable,  ex- 
cept in  cases  consulting  the  physician  after 
the  infant  has  already  grown  too  large  for 
induction.  A  six  and  a  quarter  pound 
child  has  as  good  a  chance  of  life  as  an 


the  greater  the  weight,  the  larger  the  head. 
The  diameters  of  the  head  increase  in  fairly 
definite  proportion  with  the  weight.  2. 
The  biparietal  diameter,  beaause  this 
diameter  comes  closest  into  direct  relation 
with  the  smallest  pelvic  measurement,  the 
true  conjugate  or  anteroposterior  diameter. 
If  these  two  proportions  of  the  fetus  in 
the  womb  can  be  estimated,  then  the  labor 
can  be  induced  at  such  time  as  will  give  the 
largest  child  that  can  safely  come  through 


Fig.  1. 


average  seven  and  a  quarter  pound  one  and 
lots  better  than  a  nine  pounder.  It  is  less 
battered  in  passage.  Chilling,  defective 
feeding  and  infections  are  the  dangers  of 
all  young  infants  and  these  may  with 
reasonable  care  be  avoided. 

Measuring  the  Baby. — In  measuring 
the  baby,  what  measurements  are  of  impor- 
tance?    I.  The  weight  of  the  baby,  because 


^  See    figures   and    case   reports, 
Jour.,  1912,  Mar.  9  and  16. 


A^.    Y.    Med. 


that  particular  pelvis.  We  then  have  a 
scientific  basis  for  the  obstetrical  problem. 
Any  fairly  accurate  approximation  of  the 
size  of  the  child  is  better  than  none,  because 
there  has  been  none  heretofore. 

To  attempt  to  estimate  the  weight  of  the 
baby  within  the  womb  is  best  done  by  means 
of  my  rule  for  the  duration  of  pregnancy. 
This  rule  is  strictly  a  rule  for  the  estimation 
of  the  size  of  the  child  and  is  based  upon 
the    fact    that    most    children    of    average 


Page  Fifty 


weight,  seven  and  one-third  pounds,  are 
deHvered  at  the  average  time  of  pregnancy, 
and  the  fundus  when  the  child  is  of  this 
weight  measures  35  cm.  above  the  sym- 
physis. This  then  is  the  starting  point  of 
the  scale — 35  cm.  above  the  symphysis 
equals  seven  and  one-third  pounds  (3,300 
grams).  From  this,  for  purposes  of  esti- 
mating the  weight,  deduction  may  be  made 
of  200  grams  for  every  centimeter  below  35 
cm.  Thus,  if  the  fundus  measures  31  cm. 
(this  is  four  weeks  before  term  31  -^  3>2 


centimeter,  200  for  the  second  and  250  for 
the  third  centimeter  above  that  weight. 
When  the  measurement  is  above  36  cm., 
twins  should  be  carefully  sought  for,  as 
this  has  been  in  my  hands  the  first  indica- 
tion I  have  had  of  twins  on  several  occa- 
sions. Two  babies  measure  more  than  one. 
The  measurement  should  be  taken  ac- 
cording to  the  directions  for  measuring  the 
duration  of  pregnancy  (see  illustration) 
and  the  tape  line  should  follow  the  outline 
of  the  uterus  save  at  the  last  dip.  It  should 


Fig.  2. 


=  62  -f-  7  =9  lunar  months;  see  article 
"Duration  of  Pregnancy")  the  child  weighs 
2,500  grams  and  this  weight  is  to  be  ex- 
pected at  that  time.  Induction  should 
rarely  be  done  when  the  fundus  measures 
below  30  cm.  and  in  fact  it  is  better  to  do 
it  above  this  measurement,  as  2,300  grams 
is  about  the  smallest  limit  of  weight  that 
good  results  for  the  child  are  obtained  by 
induction. 

If  the  measurement  is  above  35  cm.,  for 
estimation,    add    200   grams    for   the    first 


go  horizontally  from  the  highest  eminence 
of  the  uterine  tumor  to  the  upright  measur- 
ing hand.  This  measurement  must  be  used 
in  correlation  with  the  measurement  of  the 
head,  which  is  about  to  be  described,  and 
one  should  check  the  other. 

Measurement  of  the  head  is  done  through 
the  abdominal  wall.  The  head  lies  with  its 
longest  and  most  prominent  diameter  trans- 
versely in  the  pelvis  or  nearly  so,  and  this 
is  the  only  diameter  which  can  be  obtained. 
But   it   is   the   biparietal   diameter   that   is 


Page  Fifty -one 


wanted.  The  biparietal  diameter  of  the 
head  fortunately  bears  a  fairly  definite  rela- 
tion to  the  occipitofrontal  and  so  can  be  de- 
duced from  it.  For  that  reason,  the  occip- 
itofrontal is  measured  and  the  biparietal 
obtained  by  deduction. 

An  ordinary  pelvimeter  of  simple  con- 
struction (fig-,  i)  is  taken  and  two  rings  of 
adhesive  plaster,  about  i  cm.  in  width, 
fastened  to  each  tip.  These  rings  are 
faced  inside  with  adhesive  plaster,  back  in- 
ward,    and     are    made     sufficiently    large 


instrument  approximated  to  these  points 
as  closely  as  possible.  The  weight  of  the 
hinge  side  of  the  pelvimeter  is  supported  by 
the  finger  of  an  assistant,  or  ma^  be  held 
up  by  a  string  attached  to  the  operator's 
arm  or  buttonhole.  It  is  necessary  that 
the  hinge  side  should  have  free  play  of 
movement  in  order  that  one  or  other  tip 
may  be  depressed  if  occasion  requires.  The 
tips  are  held  firmly  against  the  cephalic 
poles  and  the  scale  is  read.  This  gives  the 
occipitofrontal    diameter.       No    deduction 


Fig.  3. 


readily  to  admit  the  middle  and  index 
fingers.  The  knob-like  tips  of  the  pelvi- 
meter should  project  about  i  cm.  beyond 
the  palpating  fingers. 

The  patient  is  laid  on  her  back  and  the 
operator  stands  as  if  to  palpate  for  the  posi- 
tion of  the  head.  An  accurate  diagnosis 
of  the  fetal  position,  not  only  in  regard  to 
the  occiput,  but  as  to  the  amount  of  flexion 
of  the  head  is  essential  to  success.  The 
bladder  must  be  empty.  The  occiput  and 
sinciput  are  located;  then  the  fingers  are 
thrust  into  the  rings  and  the  knobs  of  the 


is  required.  This  fact  is  not  satisfactorily 
explained.  The  abdominal  walls  of  a  preg- 
nant woman  are  very  thin  (usually  less 
than  I  cm,  measured  at  Caesarean  section), 
and  it  may  be  that  the  exact  prominences 
of  the  cephalic  poles  are  not  reached. 

All  heads  above  the  brim,  or  which  may 
be  thrust  above  the  brim,  can  be  measured, 
although  the  greatest  ease  is  found  in  thin 
women  with  flat  pelves  which  push  the 
head  forward.  Small  heads  with  much 
liquor  amnii  are  difficult  to  fix;  breech 
cases  offer  no  special  difficulty.     However, 


Page  Fifty-ttoo 


heads  lying  above  the  pelvic  brim  and  firmly 
placed  thereon  g-ive  the  best  conditions,  e.  g. 
in  contracted  pelves. 

The  measurement  obtained  by  this  means 
is  the  occipitofrontal  diameter,  and  from 
this  is  obtained  the  important  diameter,  the 
biparietal. 

The  amount  to  be  subtracted  varies  with 
the  size  of  the  occipitofrontal.  With  an 
occipitofrontal  diameter  of  ii.2j  cm.  two 
cm.  are  deducted  to  obtain  the  biparietal, 
from  ii.j  cm.  occipitofrontal  2.2^  cm.,  and 
from  12  cm.  occipitofrontal  2.^0  cm.  This 
amount  deducted  is  based  upon  the  follow- 
ing table  of  100  heads  measured  by  me : 

TABLE  OP  MEASUREMENTS   OF  100  NEW- 
BORN BABIES. 


Average 

No.  of 

0.  F. 

Average 

weight. 

cases. 

diameter. 

difference. 

Grams. 

1 

10 

1.00 

2,600 

4 

10.50 

1.55 

2,716 

8 

10.75 

1.81 

2,975 

17 

11 

1.91 

3,100 

21 

11.25 

2.07 

3,156 

19 

11.50 

2.26 

3,247 

9 

11.75 

2.50 

3,313 

13 

12 

2.30 

3,514 

5 

12.25 

2.35 

4,100 

1 

12.50 

2.50 

4,100 

2 

12.75 

3.12 

4,350 

It  will  also  be  noted  that  the  weight  bears 
a  fairly  definite  relation  to  the  size  of  the 
head.  This  is  of  use  in  checking  up  the 
size  of  the  child,  as  shown  by  the  author's 
rule  for  the  duration  of  pregnancy.  As, 
for  example,  with  a  fundal  measurement 
of  35  cm.  and  an  occipitofrontal  measure- 
ment of  11.50  cm.,  it  can  be  safely  estimated 
that  the  fetus  is  of  normal  size,  3,300  grams. 
In  this  way  it  is  possible  to  use  the  fundal 
measurement  and  estimated  weight  as  a 
check  upon  the  cephalimetry  with  particular 
accuracy  for  the  purpose  of  finding  this 
ratio. 

These  methods  have  been  in  use  in  my 
hands  for  seven  years  and  continue  to  give 


good  results.  In  all  I  have  measured 
eighty-four  heads  before  and  after  delivery. 
In  sixty  cases,  the  occipitofrontal  diameter 
was  correctly  estimated;  in  seventeen  cases 
there  was  an  error  of  0.25  cm.  and  in  six 
cases  there  was  an  error  of  0.5  cm. ;  and 
in  one  case  there  was  an  error  of  0.75  cm. 
This  last  case  was  not  a  fair  test,  as  the 
head  was  well  in  the  pelvis  and  could  not 
be  properly  reached.  Skill  and  practice  are 
decided  factors,  but  the  method  is  soon 
learned. 

In  addition  to  these  methods  of  measure- 
ment, an  attempt  is  made  to  estimate  the 
size  of  the  head  in  relation  to  the  pelvis. 
This  is  done  by  the  Munro-Kerr  modifica- 
tion of  Miiller's  method  and  consists  in  at- 
tempting to  force  the  head  into  the  pelvis 
by  a  grasp  above,  while  the  lower  hand  in 
the  vagina  gauges  a  descent  of  the  cephalic 
pole.  Munro-Kerr's  modification  consists 
in  holding  the  thumb  above  the  brim  of  the 
pelvis  as  well  as  the  fingers  within  the 
vagina. 

COMBINATION    OF    METHODS    N^CSSSARY. 

By  the  use  of  these  three  methods  it  is 
possible  to  gain  a  reasonably  sure  idea  as 
to  the  size  and  weight  of  the  child  before 
labor  and  so  to  form  some  idea  of  when 
labor  should  be  induced  and  what  the 
course  of  treatment  should  be.  It  should 
be  remembered  that  the  average  sized  child 
measures  35  cm.  fundal  measurement, 
weighs  3,300  grams  and  has  a  biparietal 
diameter  of  9.10  cm.,  and  with  this  as  a 
starting  point,  the  time  of  induction  is  easy 
to  reckon  for  any  known  pelvis.  These 
figures  are  based  upon  my  own  measure- 
ments. My  plan  is  to  measure  the  fetal 
head  and  uterine  fundus  from  week  to  week 
before  labor,  and  so  decide  when  induction 
should  be  done.     This  should  be  when  the 


Page  Fifty-three 


estimated  biparietal  is  a  trifle  smaller  than 
the  true  conjugate. 

These  methods  require  some  experience 
and  some  patience.  A  combination  of  the 
methods  gives  the  best  results :  he  who  de- 
pends upon  one  alone  will  be  deluded.  The 
interruption  of  pregnancy  need  not  be 
earlier  than  the  amount  of  contraction  re- 
quires, and  the  child  need  not  be  exposed  to 
the  risk  of  unnecessary  prematurity.  It  is 
but  seldom  advisable  to  induce  labor  more 
than  four  weeks  before  term,  as  then  the 
child  would  be  below  the  minimum  weight, 
2,500  grams,  for  good  results.  A  child  of 
this  weight  has  an  average  biparietal  of  8 
cm.,  the  lowermost  limit  set  for  induction 
of  labor  8  cm.,  true  conjugate. 

Watchful  attention  and  careful  measure- 
ments in  the  last  weeks  of  pregnancy  avoid 
the  dangers  of  prolonged  pregnancies  and 
large  babies,  because  the  size  and  growth 
of  the  child  are  measured  and  recognized. 
Induction  may  then  be  done  in  time.  Large 
babies  give  more  trouble  in  moderately 
contracted  pelves  than  does  the  size  of  the 
pelvis.  All  normal  sized  babies  should 
be  born  through  a  true  conjugate  of  9.25 
cm.,  equal  to  the  average  biparietal  diam- 
eter, but  the  big  fellow^s  give  the  trouble. 
The  day  will  come  when  a  ten-pound  baby 
will  become  an  accusation  to  the  accoucheur 
instead  of  a  boast  to  the  parents. 

The  head  of  a  large  baby  is  much  firmer, 
harder,  and  more  difficult  to  mould  than  that 
of  a  small  baby.  This  alteration  in  the  con- 
sistence of  the  fetal  skull  of  the  large  child 
accounts  for  the  trouble  he  causes  even 
more  than  does  the  increase  of  the  diam- 
eters of  the  head.  It  is  the  fact  that  is  re- 
sponsible to  a  large  extent  for  the  success 
of  induction  of  labor  in  contracted  pelves 
of  moderate  degree. 


CHAPTER  XIII. 

DIAGNOSIS    OF    ECTOPIC    PREG- 
NANCY. 

Introduction. — The  diagnosis  of  ectopic 
pregnancy  is  seldom  an  easy  task  and  often 
a  difficult  one.  This  is  chiefly  because  of 
the  varied  pathological  conditions  which 
may  exist  as  a  result  of  the  pregnancy  and 
its  termination.  While  the  diagnosis  is  dif- 
ficult, there  is  no  condition  in  medicine  in 
which  it  is  more  important  to  have  an  im- 
mediate and  exact  diagnosis.  If  it  is  not 
recognized,  delay  may  result  and  treatment 
for  other  conditions  be  instituted. 

Delay  in  the  treatment  of  ectopic  preg- 
nancy is  dangerous  for  several  reasons. 
The  hemorrhage  may  continue,  adhesions 
may  form  and  infection  of  the  blood  clot 
result.  All  of  these  minimize  the  patient's 
chances  of  recovery.  Movement  of  the  pa- 
tient, particularly  jolting  or  jarring  move- 
ment, is  most  dangerous  and  many  deaths 
have  been  reported  while  removing  the  pa- 
tient to  the  hospital  in  a  cab  or  ambulance. 

Mistaken  treatment  for  other  conditions, 
such  as  curettage  for  supposed  miscarriage, 
is  of  great  danger  in  ectopic  pregnancy.  It 
causes  renewed  bleeding  and  makes  opera- 
tion for  the  ectopic  pregnancy  more  hazard- 
ous. 

For  these  reasons  it  is  important  that  the 
diagnosis  should  be  made  immediately  and 
exactly.  There  is  considerable  difference 
of  opinion  in  regard  to  the  value  of  the 
various  symptoms  and  for  this  reason  I 
have  analyzed  4,000  cases  of  ectopic  preg- 
nancy in  the  literature  with  the  hope  of 
ascertaining  the  exact  value  of  each  symp- 
tom and  in  this  way  throwing  some  light 
upon  the  diagnosis.  The  cases  analyzed 
were  all   comparatively  early  ones,  before 


Page  Fifty-four 


four  months,  as  advanced  ectopic  pregnancy 
offers  an  entirely  different  problem.  These 
cases  did  not  all  give  an  expression  of  all 
the  symptoms,  and,  in  some  cases,  impor- 
tant ones  were  omitted;  but  it  has  been 
thought  better  to  give  the  percentage  value 
of  each  symptom  in  a  table  without  refer- 
ence to  the  number  of  times  each  has  oc- 
curred. 

Amenorrhea    74  per  cent. 

Uterine    hemorrhage     85 

Average  amenorrhea   40  days 

Pain    severe    66  per  cent. 

Onset  of  pain  sudden 28 

Pain  and  hemorrhage  simultaneous.90        " 
Symptoms  on  day  of  expected  men- 
struation      9         " 

Symptoms  before  the  expected  men- 
struation     17        " 

Cast  of  decidua  of  uterus 3         " 

Decidual  shreds   16         " 

Nausea    33 

Breast  changes  33        " 

Pulse  96 33 

Pulse  100  or  over 33 

Pulse  120  or  over 33 

Temperature  above  100 50         " 

Hemoglobin  almost  always  between 

30  and  70 

Leukocytes,   below   10,000 33 

,  above  15,000    33 

,  above   16,000   30 

Mass  palpable  from  abdomen 28        " 

Mass  palpable  from  vagina 88        " 

Active   bleeding  at   operation 5         " 

Free  blood  in  abdomen 90         " 

Fetus  found  at  operation 18 

Cases  in  shock  at  operation 25         " 

Average   age    25-35  years 

Greatest  number  at 30-33       " 

Uterus  displaced  by  tumor 50  per  cent. 

Vaginal   bulging    53         " 

Average  number  of  children  before 

ectopic    3.6      " 

Number  of  multiparae 83         " 

Mortality   after   operation   in    5,973 

cases    7.04    " 

Mortality       "  "  "     tubal 

rupture   17         " 

Mortality       "  "  "         " 

abortion    1.6 

Repeated  ectopic  pregnancy — 168  in 

4,180   cases  in   series 4        " 

Tubal  abortion  occurred  in 70         " 

Tubal  rupture  "  " 30         " 

Symitomatolo^.— In  considering  the 
symptoms  of  ectopic  pregnancy  it  must  be 
remembered  that  we  have  to  deal  with  a 
condition  which  may  take  different  forms 
Page  Fifty-five 


and  have  varied  terminations.  First  it  is  a 
pregnancy  and  the  symptoms  of  pregnancy 
are  usually  present.  The  women,  being 
mostly  multiparae,  have  been  pregnant 
before  and  believe  they  know  when  they 
are  in  the  family  way.  This  is  of  consider- 
able value  in  the  history. 

Amenorrhea,  a  symptom  of  pregnancy,  is 
one  of  the  most  constant  signs,  being  present 
in  three-quarters  of  all  cases.  Those  cases 
in  which  it  was  not  present  were  in  part 
cases  which  came  to  operation  before  the 
expected  date  of  the  menstruation  and  cases 
operated  upon  before  rupture. 

The  average  duration  of  the  amenorrhea 
was  40  days  and  in  only  10  per  cent,  of  the 
cases  were  two  periods  missed.  The  cessa- 
tion of  the  amenorrhea  and  the  beginning 
of  the  uterine  hemorrhage  usually  coincided 
with  the  beginning  of  pain.  It  is  true  that 
in  thirty  per  cent,  of  cases,  there  was  mild 
colicky  pain  before  the  appearance  of 
hemorrhage  and  while  the  pregnancy  was 
intact. 

Uterine  hemorrhage  was  present  in  85 
per  cent,  of  cases,  being  the  most  constantly 
present  symptom.  Cases  in  which  it  was 
not  present  were  mostly  those  which  had 
come  to  operation  before  the  date  of  the 
expected  menstruation.  Hemorrhage  came 
as  a  rule  on  the  40th  day  and  continued 
without  intermission.  It  was  continuous 
in  twelve  cases  to  one  in  which  it  was  in- 
terrupted. This  fact  is  of  great  import- 
ance in  the  diagnosis  of  ectopic  pregnancy. 

The  character  of  the  uterine  bleeding  was 
of  a  different  nature  to  the  usual  menstrua- 
tion and  women  commonly  recognize  this 
fact.  It  is  frequently  of  the  kind  known  as 
"spotting"  and  comes  constantly,  but  in 
small  amounts.  It  is  most  frequently  al- 
tered in  consistency  and  appearance.  It  is 
usually  dark  powdery  red  in  character  and 


occasionally      (i6      per      cent.)      contains 
"shreds,"  "pieces  of  flesh,"  etc. 

The  onset  of  the  bleeding-  usually  (90 
per  cent.)  coincides  with  the  onset  of  pain. 
This  is  believed  to  occur  at  the  time  at  which 
intratubal  rupture  takes  place,  to  terminate 
later  in  tubal  abortion  or  extratubal  rupture, 
as  the  case  may  be.  The  ectopic  pregnancy 
does  not  develop  within  the  mucosa  of  the 
tube,  but  underneath  the  mucosa  and 
between  the  muscular  coats.  The  first 
change  is  usually  bursting  through  the 
mucosa  to  enter  the  lumen  of  the  tube. 
When  this  occurs,  there  is  usually  first 
hemorrhage  into  the  peritoneal  cavity  from 
the  tube  and,  at  the  same  time,  the  uterine 
decidua  is  cast  off  in  the  form  of  uterine 
hemorrhage  of  the  peculiar  dark  red  color. 
After  the  decidua  is  all  cast  off,  the  dark  red 
appearance  of  the  uterine  hemorrhage  dis- 
appears. 

The  onset  of  symptoms,  pain,  etc.,  usually 
then  dates  from  the  termination  of  the 
amenorrhea  and  the  beginning  of  the  uterine 
hemorrhage.  This  is  the  time  of  the  first 
disturbance  of  the  ectopic  pregnancy.  In 
five  per  cent.,  pain  was  followed  by  bleed- 
ing, while  in  five  per  cent,  there  was  pain 
and  indisposition  without  bleeding. 

The  character  of  the  pain  was  severe  in 
two-thirds  of  all  cases.  It  was  sudden  in 
about  one-fourth  of  all  cases.  It  was  in  the 
lower  abdomen  and  usually  upon  the  af- 
fected side  in  about  sixty  per  cent.  It  was 
general  over  the  whole  abdomen  in  about 
thirty  per  cent. 

In  about  three-quarters  of  all  cases,  the 
severe  pain  was  preceded  by  pain  of  less 
severity,  which  came  on  gradually. 

The   first   pains    are   usually    sharp    and 

colicky,  while  the  severe  pain  following  is 

usually  sudden,  paroxysmal  and  cramplike. 

This  severe  pain,  which  is  sudden  and  un- 


heralded in  one-fourth  of  the  cases  and  pre- 
ceded  by   lesser   pain   in   three-fourths,    is 
variously    described    as    "cutting,"    "knife- 
like," "cramp-like,"  etc.     It  is  periodic  and 
paroxysmal,  and  is  followed  by  syncope  in 
about  one-fourth  of  the  cases.     It  is  due  to 
peritoneal  irritation  from  the  extravasation 
of  blood  from   rupture  or  tubal  abortion. 
It  is  periodic,  because  intratubal  rupture  is 
associated  with  repeated  small  hemorrhages 
which  distend  the  tube,  and  the  leaking  of 
blood   upon  the   peritoneal   surface   causes 
severe   pain,    similar   to   that    due   to    any 
foreign  substance  as  sudden  rupture  of  in- 
traabdominal abscess  or  secondary  hemor- 
rhage.    It  is  paroxysmal  in  character  and 
similar  to  pain  from  intestinal  peristalsis  in 
other  peritoneal  irritations.     In  extratubal 
rupture,    the    blood    is    extravasated   more 
rapidly,  so  that  the  pain  is  more  severe  and 
the  shock  and  collapse  more  marked.     In 
tubal  abortion  with  more  gradual  bleeding, 
the  pain  is  usually  more  persistent  and  apt 
to  recur.     The  return  of  the  paroxysm  may 
occur  several  times  a  day  and  the  character 
of  the  pain  is  periodic  and  crampy  at  these 
times. 

The  first  onset  of  the  pelvic  pain  is  asso- 
ciated with  shock  and  syncope  in  about  one- 
fourth  of  all  cases.  In  the  other  cases, 
there  is  quite  frequently  weakness  not 
amounting  to  fainting  or  syncope.  In  about 
one-half  of  the  cases  of  syncope,  from  re- 
ports at  operation,  the  shock  was  of  nervous 
origin  due  to  peritoneal  irritation  and,  in 
half  of  the  cases,  it  was  due  to  extensive 
hemorrhage  plus  peritoneal  irritation.  The 
shock  usually  occurs  once,  but  in  about  five 
per  cent,  there  were  repeated  attacks. 

In  about  one-third  of  all  cases,  there  was 
other  evidence  of  pregnancy  besides  the 
cessation  of  menstruation.  Milk,  areola  of 
pregnancy    or   tingling   of    the    nipples    is 


Page  Fifty-six 


present  in  about  one-third  of  cases  and 
nausea,  sometimes  due  to  shock,  is  present 
in  about  the  same  proportion. 

With  the  onset  of  pain  and  uterine 
hemorrhage,  there  is  usually  immediate  al- 
teration in  the  pulse  rate.  It  is  usually  in- 
creased and  often  of  the  thready  character, 
associated  with  shock.  One-third  of  the 
cases  have  a  rate  of  about  96;  one-third 
no  or  over  and  one-third  120  or  over.  So 
that  it  may  be  said  that  the  pulse  is  usually 
increased  in  rate,  and  usually  above  no. 

The  temperature  is  usually  slightly  in- 
creased in  degree.  It  is  quite  often  sub- 
normal at  the  time  of  the  acute  pain  with 
symptoms  of  intra-  or  extratubal  rupture, 
but  soon  becomes  febrile.  In  about  one- 
half  the  cases,  it  is  above  100°  and  is  sel- 
dom above  102°. 

The  hemoglobin  is  usually  decreased  in 
amount.  It  is  seldom  higher  than  70  per 
cent,  and  rarely  lower  than  30  per  cent. 
The  average  hemoglobin  finding,  where  it 
was  noted  in  these  cases,  was  49  per  cent. 
The  white  blood  count  is  commonly  in- 
creased, although  this  is  not  constant.  In 
one-third  of  cases  it  was  below  10,000,  in 
two-thirds  above  this.  In  one-third  it  was 
above  15,000,  and  one-third  above  16,000 
white  cells.  In  the  cases  of  shock,  the  leu- 
kocytosis is  usually  marked,  not  from  in- 
fection but  from  the  previous  hemorrhage. 
The  polymorphonuclear  cells  are  usually 
very  high  in  percentage  in  shock. 

There  are  sometimes  other  signs  of  peri- 
toneal irritation.  These  take  the  form  of  a 
desire  to  strain  after  defecation  and  a  feel- 
ing of  inability  to  empty  the  bowels. 
Dysuria  and  frequency  of  urination  also 
occur.  Either  one  of  these  symptoms  was 
present  in  rather  more  than  one-third  of 
all  cases. 

Examination  of  the  abdomen  seldom 
shows  any  tenderness  before  rupture,  but 
Page  Fifty-seven 


after  the  onset  of  uterine  hemorrhage  and 
pain  attending  the  termination  of  the  preg- 
nancy, tenderness  over  the  lower  abdomen 
is  almost  invariably  present.  This  is  usually 
more  marked  on  the  side  where  the  preg- 
nancy occurs.  These  symptoms  are  asso- 
ciated with  rigidity,  when  there  is  sufficient 
peritoneal  inflammation  and  irritation  from 
extravasation  of  blood.  If  the  amount  dif- 
fused be  considerable,  there  may  be  some 
distension  of  the  lower  abdomen  which  may 
be  cone-like.  Distension  and  rigidity  may 
be  absent,  but  tenderness  is  always  present. 
Tympany  is  not  uncommon  in  primary  in- 
traperitoneal rupture  with  marked  hemor- 
rhage. There  may  be  superficial  dulness 
on  percussion  over  the  pubes  and  in  either 
flank  with  a  resonant  note  on  deeper  per- 
cussion. A  thrill  may  sometimes  occur  in 
the  stomach  region,  although  no  sign  of 
fluctuation  can  be  felt.  On  turning  the  pa- 
tient over,  dulness  in  the  flanks  may  persist, 
but  gradually  disappear  in  a  way  which  is 
characteristic  of  efifusion  of  blood. 

On  vaginal  examination,  the  mucosa  is 
usually  congested,  but  not  to  the  marked 
degree  of  normal  pregnancy.  The  uterus 
is  usually  slightly  enlarged  with  a  softened 
cervix,  but  as  a  rule  none  of  the  bimanual 
signs  of  pregnancy,  as  Hegar's  or  the 
author's,  are  felt.  Intermittent  contrac- 
tions, however,  are  not  uncommon.  Move- 
ment of  the  uterus  usually  causes  pain.  A 
mass  is  felt  usually  on  one  or  other  side 
and  behind  the  uterus.  This  mass  was  felt 
in  two-thirds  of  all  cases  and  was  always 
tender.  Pelvic  tenderness  on  examination 
is  one  of  the  most  characteristic  symptoms 
of  ectopic  pregnancy. 

If  the  pregnancy  is  uninterrupted,  the 
tube  usually  prolapses  into  the  cul-de-sac  of 
Douglas;  if  rupture  takes  place,  the  blood 
seeks  the  lowest  place  and  forms  a  hemato- 
cele in  the  same  situation.     The  consistency 


of  the  mass  is  doughy  and  it  can  be  dented 
with  the  examining  finger.  The  situation 
of  the  mass  and  its  size  is  altered  by  the 
amount  of  the  extravasated  blood  and  the 
direction  it  takes.  If  the  mass  is  large,  the 
uterus  is  usually  displaced  to  the  normal 
side.  If  the  uterus  is  displaced  by  a  doughy 
tumor  which  pulsates  indistinctly,  it  is  very 
suspicious  of  ectopic  pregnancy.  The  mass 
is  usually  tense  and  elastic  and  often  lob- 
ulated.  This  elasticity  often  distinguishes 
the  condition  from  the  board-like  hardness 
of  pelvic  abscess. 

Anterior  or  posterior  colpotomy  has  been 
suggested  as  a  possible  means  of  diagnosis 
by  Bandler.  The  vaginal  vault  may  be 
opened  over  the  tumor  until  the  discolored 
peritoneum  covering  the  blood  is  seen.  The 
diagnosis  may  be  possibly  made  in  this  way 
without  opening  the  peritoneal  cavity,  the 
dark  blue  shimmer  showing  through.  Punc- 
ture of  the  posterior  vaginal  vault  through 
a  speculum  may  be  done.  If  the  cervix  is 
pulled  down  and  the  needle  thrust  directly 
in  the  mid  line  and  close  to  the  cervix,  no 
harm  can  result  and  free  blood  is  usually 
found.  Muhsam^  is  a  strong  advocate  of  this 
method  and  states  that  in  117  of  124  cases 
the  findings  were  positive,  if  not  at  once, 
after  the  woman  had  been  raised  to  a  sitting 
position.  He  ascribes  the  success  of  treat- 
ment at  the  Moabite  Hospital  of  108  cases 
without  a  death  to  early  diagnosis  and 
prompt  operative  measures.  His  greatest 
dependence  in  diagnosis  is  placed  in  punc- 
ture of  the  pouch  of  Douglas. 

Acetonuria  is  often  present  in  ectopic 
pregnancy  and  is  believed  to  be  due  to  the 
absorption  of  products  of  blood.  The  same 
is  true  of  urobilin. 

Differential  Diagnosis. — The  differential 
diagnosis    usually    requires    some   thought. 

^  Muhsam.  Therapie  der  Gegenwart,  May, 
1913. 


It  is  of  greatest  importance  to  accurately  in- 
vestigate the  history,  for  this  will  usually 
differentiate  ectopic  pregnancy  from  lesions 
with  similar  findings  upon  vaginal  exam- 
ination. The  chief  error  is  in  miscarriage, 
associated  with  some  pelvic  mass,  as  cystic 
ovary,  pus  tube,  hematosalpinx,  etc.  This 
gives  the  symptoms  of  pregnancy  with  the 
pelvic  lesion.  Miscarriage  with  retrover- 
sion of  the  uterus,  where  the  fundus  is  felt 
through  the  posterior  vaginal  fornix  is 
sometimes  very  confusing.  The  carefully 
taken  history,  the  absence  of  marked  pelvic 
tenderness,  the  different  feel  of  the  pelvic 
mass,  should  differentiate  these  conditions. 

Normal  pregnancy  in  which  there  is 
marked  asymmetrical  development  in  one 
cornua  of  the  uterus  with  marked  thinning 
and  softening  of  the  enlarged  part,  is  not 
infrequently  mistaken  for  ectopic  preg- 
nancy. This  type  of  pregnancy  is  described 
as  similar  to  a  face  with  a  toothache  and 
swollen  cheek.  It  exists  within  the  limits 
of  normal  pregnancy,  but  should  be  easy  to 
differentiate  if  the  signs  of  pregnancy,  as 
described  in  my  paper  in  another  issue,  are 
known. 

The  acute  onset  of  the  condition  makes 
it  necessary  to  differentiate  it  from  the  acute 
infections  as  appendiceal  rupture,  pelvic 
abscess,  acute  gastric  ulcer,  acute  pus  tubes 
and  acute  appendicitis. 

Peritoneal  hemorrhage  may  occur  from 
other  sources,  such  as  ovarian  hematoma, 
hematosalpinx,  ovarian  papilliferous  adeno- 
cystoma, pachysalpingitis  with  hemorrhage, 
etc.  In  all  these  cases  there  may  be  peri- 
toneal hemorrhage  which,  however,  is  not 
usually  associated  with  marked  pain  or 
symptoms  of  pregnancy. 

The  diagnosis  of  ectopic  pregnancy  is 
based  upon  the  relation  of  the  history  to  the 
physical  examination.  It  is,  as  my  teacher, 
Charles  P.  Noble,  has  often  said,  not  diffi- 

Page  Fifty-eight 


cult  in  85  per  cent,  of  cases,  difficult  in  10 
per  cent,  and  almost  impossible  in  5  per 
cent.  With  a  definite  history  of  a  lesion 
in  the  pelvis,  as  shown  by  pain,  tenderness 
and  symptoms  referable  to  the  genitalia, 
with  a  history  of  amenorrhea,  followed  by 
a  continuous  slight  hemorrhage  of  a  dark 
powdery  red  character,  different  from  men- 
strual blood,  with  paroxysmal  periodic 
pelvic  pain,  with  an  increase  in  pulse  rate, 
abdominal  tenderness  and  a  doughy  tender 
mass  beside  the  uterus,  the  diagnosis  should 
be  exact. 

Changes  in  the  uterus,  lessened  hemo- 
globin, congestive  changes  in  the  breast, 
distention  of  the  abdomen  and  alteration  in 
the  consistency  of  the  cervix,  bring  cor- 
roborative evidence  of  value. 

A  history  of  missed  menstruation,  fol- 
lowed by  severe  pain  and  uterine  hemor- 
rhage of  a  character  different  from  the 
menstruation  should  lead  one  to  suspect 
ectopic  pregnancy. 

The  most  constant  symptoms  are  amenor- 
rhea with  a  simultaneous  onset  of  uterine 
hemorrhage  and  pain.  The  cases  difficult 
to  diagnose  are  those  of  long  standing, 
where  the  hematocele  is  infected  and  the 
diagnosis  to  be  exact  should  be  infected 
hematocele. 

The  early  diagnosis  of  ectopic  pregnancy 
is  of  vast  importance  in  the  treatment  of 
the  condition.  Prompt  operative  measures 
cannot  be  instituted  unless  diagnosis  is  early 
and  exact.  Care  of  the  patient  before 
operation  is  also  of  importance.  Many 
deaths  result  from  careless  handling  in 
transportation  to  the  hospital.  Operation 
under  a  mistaken  diagnosis  as  curettage  for 
supposed  abortion  is  often  disastrous.  For 
these  reasons,  every  effort  should  be  made 
to  diagnose  ectopic  pregnancy  early  and 
exactly. 


CHAPTER  XIV. 

LACERATION     OF     THE     PERINEUM 
AND  PRIMARY  REPAIR. 

Introduction. — As  long  as  women  con- 
tinue to  have  children,  perineal  lacerations 
will  continue  to  occur.  Their  study  is  a 
commonplace  one,  not  associated  with  the 
romantic  and  imaginative  associations  as 
are  cancer  and  tuberculosis,  but  not  the  less 
necessary  and  important.  The  mere  fact 
of  the  great  prevalence,  occurring  as  they 
do  in  half  the  women  who  have  children, 
is  sufficient  to  require  that  the  study  should 
be  exact  and  persistent. 

The  cases  reported  here  were  studied  at 
labor  and  the  picture  of  the  laceration  drawn 
upon  a  stamped  outline.  This  may  now  be 
obtained  from  dealers  supplying  the  medical 
profession  with  rubber  stamps,  and  is  of 
great  use  in  the  study  and  record  of  perineal 
lacerations.  It  is  a  useful  record  to  com- 
pare after  healing  has  taken  place,  and  in- 
culcates habits  of  accuracy  in  observation. 
The  first  historical  reference  to  the  subject 
is  found  in  an  early  work  supposed  to  have 
been  handed  do\\Ti  by  tradition  and  edited 
by  an  unknown  author  who  states  that 
Tortula,  a  midwife  attached  to  the  school  of 
Salernum,  who  lived  in  the  eleventh  cen- 
tury, cured  a  laceration  of  the  perineum  by 
operation — "Postmodum  ruptura  intra  aniim 
et  vidvam  tribiis  locis  vel  qiiatiior-  suimus 
cum  filo  de  serico."^ 

.Ambrose  Pare-  was  another  of  the  early 
investigators  of  the  subject  and  is  credited 
with  having  performed  the  operation.  He 
reports  a  cure  of  two  cases,  but  does  not 
state  that  the  operation  was  done  imme- 
diately after  labor.  He  gives  directions  as 
follows :  "But  if  through  the  violence  of 
extraction  the  genital  parts  are  torn,  so 
that  the  two  cavities,  the  rectum  and  vagina, 


Page  Fifty-nine 


are  torn  into  one,  the  tear  must  be  stitched 
up,  and  the  wound  cured  according  to  art. 
I  have  thus  cured  two  women  living-  in 
Paris." 

Various  other  investigators  followed 
Pare,  amongst  them  his  pupil,  Guillemeau,^ 
who  operated  upon  one  case  of  complete 
rupture  of  the  perineum  six  weeks  after 
labor.  He  pared  the  edges  of  the  old 
cicatrix  and  used  one  figure-of-eight  and 
two  interrupted  sutures.  The  operation 
was  a  success.  Others  who  performed  the 
operation  for  complete  tear  were  De  La 
Motte,  Morlanne,  Saucerotte,  Noel,  and 
Dupuytren  in  France,  Rowley  in  England, 
and  Oslander  and  Dieffenbach  in  Germany, 
Dieffenbach*  wrote  extensively  upon  the 
subject  of  complete  perineal  tear  and  fol^ 
lowed  the  plan  of  making  lateral  incisions 
at  each  side  of  the  perineum  after  suturing 
the  recto-vaginal  septum.  In  1837  he  ad- 
vised the  primary  repair  of  all  lacerations 
of  the  perineum,  including  first  and  second 
degree  tears. 

Amongst  American  surgeons  Mettauer^ 
of  Virginia  published  a  report  of  a  success- 
ful operation  for  complete  tear  six  months 
after  its  occurrence.  He  used  sutures  of 
lead  and  fastened  them  by  twisting. 

Roux^  wrote  extensively  upon  the  sub- 
ject and  published  many  successful  cases  of 
complete  perineorrhaphy.  He  was  an 
earnest  advocate  of  the  operation. 

Amongst  those  who  did  primary  opera- 
tions for  incomplete  tears  of  the  perineum 
were  Bayer^  in  1823,  ChurchilP  in  1824,  and 
Williams^^  in  1827,  while  Alcock^^  per- 
formed the  intermediate  operation  for  in- 
complete laceration  in  1820. 

The  secondary  operation  for  laceration 
of  the  second  degree  tears  also  was  first 
done  about  this  time.  Fricke,^^  in  1835, 
has  done  the  operation    four    times    with 


three  successes.  Nick^^  also  reported  in 
1838  that  he  had  done  two  operations  for 
incomplete  tear  of  the  perineum.  Baker 
Brown^^  was,  however,  the  sureeon  who 
did  most  to  bring  the  operation  into  general 
use  and  encouraged  others  to  study  the  sub- 
ject of  perineal  injuries.  In  1866,  Baker 
Brown  had  done  112  operations  upon  the 
perineum.  His  work  stimulated  Savage^® 
to  excellent  researches  upon  the  anatomy  of 
the  perineum,  which  have  remained  classic 
in  gynecological  literature. 

Following  after  these  were  Hegar,  Sims, 
Agnew,  Emmet,  A.  Martin,  and  Lawson 
Tait.  Of  these,  Emmet"  has  been  the 
greatest  contributor  toward  the  subject  and 
recognized  that  the  torn  muscles  and  fasciae 
caused  a  loss  of  support  to  the  pelvic  floor. 
His  operation  is  the  one  commonly  per- 
formed at  the  present  time. 

Since  the  time  of  these  masters,  a  multi- 
tude of  new  operations  have  been  devised 
to  restore  the  anatomical  support  of  the 
pelvic  floor  and  close  the  perineal  wound, 
caused  by  descent  of  the  head  at  labor.  All 
these  operations  have  as  their  aim  the  in- 
timate approximation  of  the  edges  of  the 
torn  fasciae  and  muscles.  To  this  end,  in 
secondary  operations,  many  forms  of  de- 
nudation of  the  vaginal  mucous  membrane 
have  been  exploited.  The  majority  of  these 
attempt  the  excision  of  the  scar  tissue  of 
the  old  wound  and  the  restoration  of  the 
torn  muscles  and  fasciae. 

Without  a  proper  appreciation  of  the 
causes,  processes,  and  forms  of  perineal 
rupture,  it  is  useless  to  attempt  to  judge 
the  value  of  each  modification  of  the  various 
operations.  With  this  end  in  view  I  have 
made  sketches  of  forty-eight  consecutive 
perineal  lacerations  at  the  time  of  labor  and 
have  noted  the  most  evident  and  directly 
causative  factors.       These  lacerations  oc- 


Page  Sixty 


curred  in  loo  women,  of  whom  90  were 
primiparae.  This  gives  a  percentage  of 
occurrence  of  forty-eight  per  cent.,  which 
is  within  Williams'  estimate  of  45  to  58  per 
cent.  Every  wound  of  the  mucous  mem- 
brane other  than  a  small  tear  of  the 
fourchette  has  been  reckoned  in  the  series, 
none  over  1.5  c,  m.  in  length  have  been 
excluded. 

Causes. — The  various  causes  of  perineal 
laceration  are  usually  cited  as  follows:  i. 
Too  rapid  expulsion  of  the  child,  so  that 
tearing  of  the  perineum  instead  of  stretch- 
ing results;  2.  Relative  disproportion 
between  the  presenting  part  and  the  par- 
turient outlet;  3.  A  faulty  mechanism  of 
labor  whereby  the  largest  circumference  of 
the  head  passes  the  perineal  ring;  4.  The 
use  of  forceps. 

Rapidity  of  delivery  is  without  doubt  the 
most  frequent  cause  of  perineal  laceration. 
This  is  particularly  seen  in  those  cases  of 
precipitate  delivery  where  the  head  comes 
through  the  birth  canal  rapidly  and  impinges 
upon  the  perineum  with  almost  the  force  of 
a  blow.  This  rapidity  of  advancement  of 
the  head  is  sometimes  seen  in  cases  of  con- 
tracted pelvis,  where  strong  uterine  pains 
are  required  to  force  the  head  through  the 
bony  pelvis,  with  the  result  that  the  less 
resistance  of  the  soft  parts  does  not  retard 
its  way.  The  quick  descent  of  the  head 
was  also  seen  in  one  case  (No.  25),  where 
the  membranes  had  remained  intact  until 
the  head  had  come  through  the  brim ;  when 
the  membranes  ruptured,  the  head  was  ad- 
vanced with  great  rapidity,  causing  a  lacera- 
tion in  a  multipara  with  a  comparatively 
lax  outlet. 

The  passing  of  the  head  through  the 
perineal  outlet  should  undoubtedly  be  re- 
tarded, until  the  parts  have  softened  and 
stretched.     A   preliminary    digital    stretch- 


ing is  most  useful  in  primiparae,  although 
often  a  painful  procedure.  It  can,  however, 
be  done  during  the  labor  pains  and  is  a 
means  of  stimulation  of  their  force  and  fre- 
quency. 

A  frequent  cause  of  perineal  laceration  is 
the  pressure  of  the  head  upon  the  perineal 
body  and  the  lack  of  retraction  between 
pains.  The  maternal  parts  become  blood- 
less and  tense  and  tear  readily  with  further 
descent  of  the  head.  An  additional  factor 
in  the  production  of  this  condition  is  the 
attempt  to  control  expulsion  by  pressing 
the  taut  perineum  against  the  sinciput. 
This  wounds  the  perineum  and  aids  in  the 
production  of  the  anemic  condition.  The 
advancement  of  the  head  should  be  con- 
trolled without  making  any  pressure  upon 
the  perineum. 

Strong  pains  are  a  definite  factor  in  the 
production  of  perineal  injuries,  but  may  be 
readily  controlled  by  chloroform. 

Relative  disproportion  between  the  pre- 
senting part  and  the  parturient  outlet  is 
commonly  thought  to  be  one  of  the  main 
causes  of  perineal  injuries. 

In  any  attempt  to  estimate  the  size  of 
the  fetal  head  in  relation  to  the  perineum, 
it  should  be  decided  which  is  the  greatest 
diameter  of  the  fetal  head  to  engage  in  the 
perineal  ring.  In  this  study,  it  will  be  con- 
sidered to  be  the  occipito-frontal  diameter, 
which  comes  into  relation  with  the  perineum 
by  the  final  extension  of  the  head.  It  is 
the  diameter  most  capable  of  accurate 
measurement  and  gives  a  more  dependable 
estimate  of  the  size  of  the  fetal  head  than 
do  the  suboccipito'-bregmatic  or  biparietal 
diameters.  The  various  circumferences  of 
the  fetal  head  offer  too  much  possibility  of 
error  in  measurement  to  make  them  useful 
as  indications. 


Page  Sixty-one 


Therefore,  in  attempting-  to  estimate  the 
size  of  the  presenting-  part  in  its  relation  to 
the  size  of  the  perineal  ring,  the  greatest 
engaging  diameter,  the  occipito-frontal,  is 
taken  as  a  criterion.  However,  as  the  size 
of  the  head  increases  in  direct  proportion  to 
the  weight  of  the  child,  the  increase  of 
weight  in  its  relation  to  perineal  lacerations 
is  also  considered.  This  increase  in  the 
size  of  the  fetal  head  in  proportion  to  the 
weight  was  shown  to  be  constant  in  lOO 
cases  studied  in  its  relation  to  intra-uterine 
cephalimetry.^'' 

Varieties. — In  this  series,  the  48  perineal 
lacerations  may  be  divided  into  two  classes : 
I.  Those  not  involving  the  muscle;  and  2. 
Those  involving  the  muscle  of  the  perineum. 
Of  those  not  involving  the  muscle,  there 
were  21.  The  average  weight  of  the  21 
babies  was  3,310  grammes,  and  the  average 
occipito-frontal  diameter  was  11.27  cm. 
The  27  cases  of  lacerations  involving  the 
muscle  had  children  averaging  3,550 
grammes,  and  with  an  average  occipito- 
frontal diameter  of  11.75  c"^-  I'he  average 
weight  of  100  babies,  of  whom  these  48 
cases  here  reported  are  a  part,  was  3,300 
grammes,  and  the  average  occipito-frontal 
diameter  was  11.40  cm.  Therefore  the  re- 
sult may  be  summarized : 

O.F. 

Diam.       Weight. 

21  cases  of  laceration  not  in- 
volving  muscle    11.27     3,310  gm. 

27   cases   of   laceration   involv- 
ing muscle   11.75     3,550  gm. 

100  cases,  including  48  cases  of 

laceration    11.40     3,300  gm. 

From  this  summary  it  will  be  seen  that 
the  babies  causing  lacerations  not  involv- 
ing the  skin  were  of  average  weight,  but 
of  less  than  average  size  of  head ;  while 
those  causing  lacerations  involving  muscle 
were  of  more  than  average  weight  and  size 


t)f  head.  However,  the  slight  increase  in 
weight  of  two  hundred  grammes  (7  oz.) 
can  hardly  explain  the  causation  of  the 
lacerations  in  view  of  the  fact  that*T:he  heads 
were  but  slightly  larger  than  average.  Nor 
will  the  fact  that,  in  21  cases  of  minor 
lacerations,  the  fetus  was  of  average  weight 
and  less  than  average  size  of  head  explain 
the  causation  of  these  tears. 

The  causation  of  perineal  lacerations, 
while  undoubtedly  influenced  by  consider- 
able increase  in  size  of  the  fetal  head,  does 
not  depend  to  any  extent  upon  this  condi- 
tion. It  must,  therefore,  depend  more  upon 
the  size  and  condition  of  the  perineum  itself 
than  upon  the  size  of  the  fetus  and  fetal 
head.  The  disproportion  may  be  due  to 
firmness  of  fiber  and  rigidity  of  perineal 
structure. 

Faulty  mechanism  of  labor  is  undoubt- 
edly the  cause  of  a  small  percentage  of 
lacerations,  but  this  has  an  influence  in  but 
a  small  number  of  cases.  Amongst  them 
are  those  cases  where  the  occiput  does  not 
present  under  the  symphysis  as  in  delivery 
by  face  to  pubes.  Whenever  the  flexion  of 
the  head  is  not  sufiicient,  a  larger  diameter 
than  necessary  must  pass  the  perineal  ring. 
If  flexion  is  good,  the  occiput  may  pass 
under  the  pubic  bones  before  the  occipito- 
frontal diameter  engages  in  the  outlet. 

In  breech  deliveries  the  reverse  must 
ensue,  i.  e.,  the  occiput  remain  within  the 
ring  and  pivot  under  the  symphysis,  allow- 
ing the  sinciput  to  engage  first  in  the  ring. 

The  use  of  forceps  as  a  causative  force 
is  one  which  varies  very  much  with  the 
methods  of  different  operators.  The  harm 
they  cause  depends  upon:  i.  The  kind  of 
forceps  employed;  and  2.  Upon  whether 
the  operator  delivers  the  head  with  the 
forceps  or  not. 


Page  Sixty-two 


Forceps  with  long  blades  of  the  type  of 
the  Simpson  forceps  may  cause  laceration 
of  the  perineum  in  two  ways.  First, 
directly  on  a  backward  pull  by  the  breadth 
between  the  shanks  where  they  join  the 
handles,  which  unduly  stretches  and 
wounds  the  outlet  at  a  level  with  its  great- 
est frailty,  the  posterior  fourchette.  Second, 
the  blades  themselves  do  not  closely  ap- 
proximate the  fetal  head,  and  the  edge  of 
the  blade  extending  beyond  the  head,  im- 
pinges upon  the  vaginal  floor  and  is  forced 
into  the  tissue.  This  condition  is  quite 
common  when  attempts  are  made  to  deliver 
the  head  through  the  ring  without  removing 
the  forceps.  When  the  handles  of  the 
forceps  are  turned  upward  in  order  to  ex- 
tend the  head,  the  blades,  not  fitting  snugly 
over  the  head  but  grasping  the  parietal 
processes  firmly,  turn  upon  these  eminences 
as  upon  a  pivot,  with  the  result  that  the 
point  of  the  blade  extends  beyond  the  head 
and  impinges  upon  the  pelvic  floor.  Further 
descent  of  the  head  drives  the  point  into 
the  tissue  and  starts  a  laceration.  In  such 
conditions  it  requires  but  a  small  beginning 
of  a  tear  in  the  mucous  membrane  to  result 
in  a  large  laceration. 

The  secret  of  success  in  the  prevention  of 
perineal  lacerations  is  to  keep  the  mucous 
membrane  intact :  once  the  mucous  mem- 
brane is  ruptured,  as  by  the  point  of  the 
forceps'  blade,  the  head  stretching  these 
tissues  often  causes  a  severe  tear,  while,  if 
the  mucous  membrane  is  kept  intact,  de- 
livery is  often  made  successfully  through 
most  rigid  perinea.  In  other  words,  the 
tissues  are  like  cotton,  in  which,  if  a  tear 
is  once  begun,  it  may  be  easily  extended. 
Such  was  the  result  in  one  case  (No.  7), 
here  reported,  where  a  small  laceration  was 
caused  by  the  points  of  the  Elliott  forceps 


and  the  muscles  split  so  that  the  finger 
could  be  thrust  between  the  muscular  planes 
to  the  skin  of  the  ischiorectal  space. 

It  is  necessary  in  delivery  to  prevent  the 
parturient  from  slipping  away  from  the 
hand  protecting  the  perineum  during  de- 
livery. The  diameter  of  the  fetal  head  from 
the  brow  to  the  back  of  the  neck  should  be 
brought  into  the  median  line.  The  right 
hand  restrains  the  sinciput  or  forehead; 
while  the  left  index  and  middle  fingers  are 
worked  into  the  angle  below  the  symphysis 
and  lift  the  back  of  the  head  until  the  back 
of  the  neck  enters  the  symphygeal  angle. 
The  soft  parts  are  pushed  backward  over 
the  dip  of  the  occiput  in  order  that  the  oc- 
ciput may  be  delivered  before  the  sinciput 
and  the  head  escape  delivery  in  the  long- 
est diameter,  the  occiput  frontal.  As  soon 
as  the  head  is  under  control  the  patient 
should  be  instructed  to  count  rapidly  or  to 
take  deep  rapid  breaths  in  order  to  eliminate 
further  straining.  If  chloroform  is  given, 
the  straining  may  be  controlled  in  this  way. 
The  occiput  must  be  delivered  before  exten- 
sion of  the  head  is  allowed. 

Stretching  the  perineum  is  always  ad- 
visable before  forceps  operation.  Some- 
times this  may  be  done  by  dilatation  of  the 
vagina  by  a  rubber  bag  as  first  advised  by 
Macomber.  This  is  so  painful  as  not  to 
be  permitted  until  an  anesthetic  is  given, 
but  manual  dilatation  by  massage  and 
stretching  is  useful  before  operative  de- 
liveries. 

It  should  be  remembered  that  the  essen- 
tial part  of  the  perineum  is  composed  of 
fascia  and  muscle  and  that  fascia  will  not 
stretch,  while  muscle  will.  The  fold  of 
skin  and  superficial  fascia  extends  for  3  or 
4  cm.  beyond  the  musculature  below.  For 
this  reason,  in  order  to  avoid  laceration  into 
the   muscle,   where  a   laceration   must   ob- 


Page   Sixty-three 


viously  occur,  an  incision  or  episiotomy 
may  be  made  for  2  cm.  or  a  thumb's  breadth 
into  perineum  without  cutting  into  muscle. 

This  allows  of  enough  enlargement  of 
the  outlet  and  is  more  readily  repaired  than 
is  a  perineal  tear.  The  incision  should  be 
made  backward  and  downward  and  at  the 
side  below  the  outlet  of  the  vulvovaginal 
gland.  This  is  a  useful  procedure,  not 
sufficiently  used.  It  was  known  centuries 
ago  and  referred  to  by  Harvey,  discoverer 
of  the  circulation  of  the  blood  and  by  De 
La  Motte  who  was  a  close  observer  of  peri- 
neal injuries.  It  may  be  very  readily  re- 
paired with  No.  2  chromic  gut.  v.  Ott  has 
done  364  episiotomies  and  is  most  laudatory 
of  the  operation. 

The  secret  of  avoidance  of  tears  in  for- 
ceps delivery  is  the  use  of  proper  forceps 
and  the  removal  of  the  forceps  as  soon  as 
the  head  can  be  controlled  by  the  hand. 

Trials  by  practical  use  of  many  models 
show  that  semi-fenestrated  forceps  as  de- 
scribed in  a  previous  chapter,  fit  the  head 
well,  cause  little  traumatism  to  the  vagina 
and  perineum,  and  are  easily  applied  with- 
out causing  abrasions  or  injury.  These 
forceps  may  be  applied  and  the  head  drawn 
down  until  it  can  be  controlled  by  pressure 
upon  the  forehead  between  the  coccyx  and 
the  anus.  No  attempt  should  be  made  to 
deliver  the  head  without  first  removing  the 
forceps. 

With  the  acquirement  of  skill  and  the 
use  of  proper  forceps,  there  is  no  reason 
why  there  should  be  more  lacerations 
directly  due  to  forceps  in  instrumental  de- 
liveries than  in  non-instrumental  deliveries. 
The  head  may  be  delivered  as  slowly  and 
as  much  care  taken  of  the  perineum  as  in 
non-instrumental  deliveries. 

A  frequent  cause  of  perineal  laceration 
which  is  often  credited  to  the  forceps  opera- 


tion is  the  traumatism  done  by  the  pro- 
longed stay  of  the  head  at  the  outlet  and 
the  pressure  caused  by  the  ineffectual  labor 
pains  pressing  the  presenting  pai^  against 
the  pelvic  diaphragm.  In  those  cases 
(Nos.  19,  30  and  38)  in  which  the  head 
had  remained  some  time  upon  the  pelvic 
floor,  the  resulting  lacerations  were  exten- 
sive and  deep;  the  tissues  were  edematous 
and  fragile,  being  repaired  with  difficulty, 
as  the  sutures  cut  out.  The  presenting  head 
should  not  be  allowed  to  remain  upon  the 
perineum  without  advance  for  more  than 
an  hour  and  a  half,  and  usually  not  that 
time. 

Posterior  positions  are  also  often  spoken 
of  as  a  cause  of  perineal  lacerations  and 
undoubtedly  predispose  to  this  condition. 
Forceps  rotation  is  dangerous  with  the  old 
style  long  fenestrated  forceps.  The  vaginal 
mucous  membrane  may  be  stripped  off,  as 
was  the  result  in  one  case  (No.  32),  re- 
ported here.  However,  with  the  modern 
solid  blade  model,  the  operation  of  rotation 
by  forceps  is  easy,  and  there  is  but  little 
danger  of  damage  to  the  mucous  mem- 
brane. 

Scar  tissue  in  the  perineal  ring  as  a  result 
of  old  wounds  or  previous  perineorrhaphies 
makes  the  perineum  more  easily  torn.  The 
fibrous  scar  tissue  has  not  the  elasticity  of 
normal  perineal  structure,  and  rupture  is 
apt  to  occur  at  this  spot.  In  several  cases 
of  multiparae  (Nos.  5,  8  and  39),  the  peri- 
neal outlet  was  of  fair  size,  yet  a  laceration 
occurred  at  the  site  of  the  scar. 

It  is  frequently  stated  that  the  shoulders 
in  head  presentations  often  cause  lacera- 
tions of  the  perineum.  Such  is  not  my  ex- 
perience. The  shoulders  alone  seldom 
originate  a  laceration;  but  large  shoulders 
quite  frequently  increase  the  extent  of  a 
tear  which  was  begun  by  the  head.     The 


Page  Sixty-four 


phenomenon  already  referred  to  holds  good 
that  a  tear  once  begun  readily  extends ; 
such  was  the  result  in  one  case  (No.  i8) 
in  this  series. 

For  the  purpose  of  consideration  of  these 
lacerations,  they  may  be  divided  into  tears 
of  the  anterior  and  posterior  part  of  the 
perineal  outlet.  The  posterior  tears  may 
again  be  divided  into: — i.  Tears  not  in- 
volving the  muscle,  or  minor  tears ;  2.  Tears 
involving  the  muscle,  or  major  tears ;  and 
3.     Tears  involving  the  sphincter. 

The  relation  of  the  skin  surface  to  the 
lacerations  has  no  bearing  upon  its  depth 
or  gravity.  Ofttimes  a  laceration  may  not 
involve  the  skin  surface,  yet  extend  deep 
into  the  muscle  of  the  pelvic  floor.  Such 
cases  are  Nos.  7,  24,  27  and  36.  There 
may  be  extensive  injury  to  the  pelvic  mus- 
cular support  without  any  rupture  of  skin 
surface. 

Minor  lacerations  occurred  21  times. 
Forceps  were  done  4  times.  The  average 
weight  of  the  babies,  as  before  stated,  was 
3,310  grammes. 

Major  lacerations  occurred  27  times. 
There   were    11    forceps   deliveries.       The 


average   weight   of   the   babies    was   3,550 
grammes. 

No  cases  of  sphincter  tear  occurred  in 
this  series.  The  author  has  repaired  a 
number  of  sphincter  lacerations  in  ob- 
stetrical work  and  has  had  two  occur  in 
his  own  hands.  One  of  these  was  due  to 
an  ill-directed  and  ill-controlled  forceps 
traction  when  the  head  was  near  the  peri- 
neum. The  head  came  down  suddenly 
with  the  last  traction,  and  as  the  direction 
of  the  traction  was  wrong,  ruptured  the 
perineum.  The  other  case  was  one  in 
which,  while  an  assistant  delivered  a  case 
of  placenta  previa  under  my  direction,  the 
arms  became  extended  in  the  breech  extrac- 
tion and  caused  delay,  so  that  the  safety  of 
the  child  compelled  extraction  of  the  head 
very  hurriedly.  The  head  came  through 
the  pelvis  so  quickly  that  the  extension  of 
the  face  was  not  done.  The  chin  caught 
against  the  perineum  and  caused  a  sphincter 
laceration.  Both  of  these  tears  should 
have  been  prevented.  Most  sphincter 
lacerations  are  without  excuse,  and,  with 
proper  care,  should  not  occur. 


Page  Sixty-five 


TABLE  OF  CASES. 


Para. 


I] 
II] 


II] 


Occ. 

Pelvis.  Fr. 

Normal     12.75 

12 

11 

11.25 

si.   contr 11.5 

"     11.75 

Normal    11.75 


.12 


Contracted    11.5 

11.75 

11.25 

Normal     11.25 

11.25 

10.50 

11.25 

si.   contr 10.75 

Normal     11.25 

si.   contr 11.50 

Normal     11.75 


.12 

.11.75 

.12 

.11.5 

.11 

.10.75 


11 

10.5 

Contracted    12.25 

Normal     11.5 

si.   contr 10.75 

Normal     11.25 

11.25 

11.25 

10.30 

11 

si.   contr 10.75 

Normal     11.5 

11 

11.50 

11.25 

12 

11.75 

11.50 

11.50 

si.   contr 11.25 

Normal     11.25 

11 

11.25 


Weight. 
3600 
3500 
3300 
3400 
2900 
3900 
3450 

3950 
3050 
4000 
2850 
3100 
3650 
2950 
3400 
2800 
3600 
3700 
3800 

3750 
3600 
3500 
3025 
2950 
3200 

3200 
3100 
3800 
3650 
3000 
3500 
3300 

3100 
3500 
2650 
2900 
3800 
2650 
3800 
3500 
3300 
3200 
3400 
3500 
3400 
3000 
3000 
3200 


Remarks. 

Precipitate.    Age  39. 

Scar  of  old  operation  caused  rigidity. 

Med.    forceps.    Muscle    split    begun    by    sharp 

edge   of  forceps. 
Old   scar  tissue. 

High   forceps;    torn  after   removal.. 
High  forceps,  dry  labor. 

Low  forceps. 


Tear  increased  by  large  shoulders. 
R.  O.  P.  Head  on  perineum  l^^  hours,  tissues 
contused. 

Low  forceps. 


Second  degree.     Skin  intact. 
R.  0.  P.     Head  came  down  quickly  when  mem- 
branes  ruptured. 

R.    0.   P.     Second   degree. 

Med.  forceps. 

Low  forceps. 

Low  forceps.    Head  on  perineum  iy2  hours. 

Med.  forceps.    L.  0.  P.    Caused  by  attempts  at 

rotation. 
R.  0.  P.     Low  forceps.     Age  44. 
Very  rigid. 


Med.  forceps. 
Low  forceps. 
Low  forceps. 
Med.  forceps. 


Med.  forceps. 


Dry  labor. 

Head  on  perineum  1%  hours. 
Old  scar  of  previous  repair. 


Page  Sixty-six 


^1  \ 


repaired 


beep  sejbara-l 
tion  of  muscksi 
to  sA/w  in     wf, 

rectal    I  ^  , 
space    -V/,,^ 


f,   '^ 


E*IQ.    1. 


Page  Sixty-seven 


Fig.  2. 


Page  Sixty-eight 


old 

cystoeek 


muco 
cut-     ,v„, 
junc.  ;^', 


^^     Jf\ 


ft"^ 


Ol\^ 


3^  iih^- 


MN 


<^^  p 


Pig.  3. 


Page  Sixty-nine 


7,^c  scar 


¥2     /j^ 


¥3     } 


.7^!^, 

?w^ 


^^/'/ 

3^3 

"/l\^ 


Fig.  4. 


Page  Seventy 


In  consideration  of  these  48  cases,  it  will 
be  seen  that  lacerations  of  the  anterior  por- 
tion of  the  perineal  ring  have  occurred  32 
times.  These  lacerations  occurred  in  the 
region  of  the  vestibule,  through  the  labia 
minora  and  around  the  urethral  orifice. 
They  frequently  caused  hemorrhage.  In 
one  case   (No.  14)   the  labium  minus  was 


A  scrutiny  of  the  more  severe  tears  of 
this  series  will  show  that  the  lacerations  are 
usually  lateral.  Those  which  occurred  in 
the  midline  did  not  extend  centrally  up  the 
vagina,  but  deviate  to  one  or  other  side,  or 
separate  to  form  a  Y.  The  only  lacerations 
which  extended  centrally  up  the  vagina 
were  those  in  which  the  perineum  was  the 


Fig.  5. 


torn  completely  through,  as  if  cut  with 
scissors.  These  anterior  tears  have  but 
seldom  been  referred  to  save  by  Bar  and 
Hirst  and  are  of  considerable  importance, 
as  they  often  bleed  profusely.  A  death 
from  hemorrhage  from  an  anterior  lacera- 
tion has  been  referred  to  by  Mathews 
Duncan. 


seat  of  old  scar  tissue  which  altered  the 
normal  relation  of  the  fibers. 

Thus  it  will  be  seen  that  any  secondary 
operation  which  considers  purely  the  mid- 
dle line  of  the  vagina  does  not  attempt  to 
repair  the  original  trouble  and  is  ineffectual 
in  restoring  the  parts  to  their  previous  con- 
dition.    The  Emmet  operation,  as  modified 


Page  Seventy-one 


by  Noble,  best  completes  the  exact  anatomic 
restoration  for  primary  repair.  It  may  be 
modified  to  suit  any  of  the  more  severe 
lacerations  shown  in  these  pictures. 

These  lacerations  were  all  repaired  imme- 
diately after  labor.     The  operation  may  be 

L 


operation  done.  The  intermediate  opera- 
tion in  the  stage  of  g-ranulation  is  one 
fraug-ht  with  danger.  Freshening  the 
granulating  surfaces  of  an  infected  wound 
of  the  perineum  may  cause  a  severe  in- 
toxication and  open  avenues  of  infection. 


//  /  / 


Fig.  6. 


delayed  24  to  28  hours,  if  the  woman's 
condition  is  poor,  but  should  not  be  delayed 
longer,  as  the  pyogenic  organisms,  con- 
stantly in  the  lochia,  may  cause  infection  of 
the  wound.  If  it  is  necessary  to  delay 
longer,  the  laceration  should  be  left  for 
complete    cicatrization,    and    a    secondary 


The  technique  of  the  operation  for  pri- 
mary repair  was  as  follows :  First,  if  there 
was  a  sphincter  tear,  the  rectum  was  sutured 
by  a  modified  Lauenstein  suture  with  fine 
chromic  catgut  and  a  small  needle.  These 
sutures  pass  in  and  out  close  to  the  margin 
of  the  gut  upon  the  vaginal  side  without 


Page  Seventy-two 


penetrating-  the  rectal  mucosa.  They  are 
introduced  in  a  figure-of-eight  and  tied  not 
overtightly.  The  remainder  of  the  opera- 
tion, save  for  joining  the  sphincter  ends,  is 
the  same  as  for  a  sphinter  or  major  tear. 

The  mucous  membrane  is  sutured  with 
No.  2  chromic  catgut,  with  a  Kelly's  needle. 
These  needles  should  be  rather  heavy ;  a 
useful  type,  with  a  large  (Lister's)  eye  in 


These  double  stitches  save  time,  lessen  the 
possibility  of  infection  along  the  suture 
line  and  properly  coaptate  the  parts.  Care 
should  be  taken  that  the  sutures  completely 
close  the  sulci  and  do  not  connect  them  into 
closed  gutters  for  the  passage  of  discharges. 
Twelve-day  chromic  gut  is  used  and  lasts 
in  the  vagina  from  six  to  ten  days.  Plain 
catgut  is  not  of  use  in  the  soft  succulent 


Fig,  7.     Illustrating    Laceration    of    Perineum 


the  side,  is  that  sold  by  Codman  and  Shurt- 
leff  of  Boston.  The  needle  should  be  in- 
serted I  cm.  from  the  edge  of  the  mucous 
membrane  and  come  out  at  the  bottom  of 
the  laceration ;  be  reinserted  and  emerge  i 
cm.  from  the  opposite  edge  (Fig.  7).  Full 
bites  of  tissue  should  be  taken.  The  sutures 
here    are    also    passed    as    figure-of-eight. 


tissues  of  the  postpartum  passages,  as  it  is 
absorbed  too  rapidly.  No.  3  plain  catgut 
lasts  on  an  average  three  days  under  these 
conditions. 

If  the  laceration  is  complete,  the  sphincter 
is  now  brought  together  by  two  sutures  of 
No.  I  chromic  catgut  on  a  small  needle. 
These  sutures  are  buried  (Fig.  8). 


Page  Seventy-three 


The  next  step  in  the  operation  is  the 
closure  of  the  external  or  skin  surface  of 
the  laceration:  this  is  done  by  silkworm  or 
chromic  gut  sutures,  with  the  Kelly  needle. 
The  sutures,  as  passed  through  one  side  of 
the  wound,  come  out  at  the  bottom  and,  if 
necessary,  pick  up  any  redundant  tissue, 
and  are  reinserted  to  come  out  about  i  cm. 
from  the  skin  surface.     These  sutures  are 


pull   the  edges    of    the    wound    together. 

_When   all   are   inserted,   these   sutures  are 

tied. 

Attention  is  then  directed  to  the  muco- 
us 

cutaneous  junction  at  the  level  of  the  hymen. 
Here  two  or  three  fine  chromic  sutures  are 
usually  required  to  effectually  seal  the 
wound. 

The  secret  of  success  and  primary  union 


Fig.   8.      Illusteating  Laceration   of  Perineum 


drawn  sufficiently  tight  to  bring  the  edges 
of  the  wound  firmly  together.  It  usually 
requires  from  three  to  five  of  these  sutures. 
None  should  be  tied  until  all  are  in  place, 
the  effect  of  each  suture  upon  the  wound  by 
crossing:  the  ends  of  the  suture  beingf  to 


in  this  operation  is  to  have  no  opening  or 
gap  in  the  line  of  the  wound  for  the  en- 
trance of  the  lochial  discharges  which  have 
been  proved  always  to  contain  pyogenic  or- 
ganisms. These  last  chromic  gut  stitches 
effectually  block  a  very  commonly  left  gap 


Page  Seventy-four 


which  would  permit  the  infiltrating  dis- 
charge to  obtain  entrance  to  the  lower  part 
of  the  wound.  These  stitches  correspond 
to  the  "crown-stitch"  of  Emmet's  operation 
and  restore  the  fascia  in  that  plane  as  well 
as  add  to  the  cosmetic  result. 


are  not  so  succulent,  nor  are  they  so  ex- 
posed to  discharges,  as  to  require  chromic 
gut.  The  difficulty  in  the  repair  of  these 
anterior  tears  is  to  avoid  puckering  and  to 
get  a  straight  line  of  union.  This  is  best 
done   by  beginning  the   continuous   suture 


Fig.   9.      Illustrating   Laceration  of  Perineum    (Chapter  14). 


The  operation  is  done  in  three  steps:  i. 
Suturing  the  mucous  membrane;  2.  Sutur- 
ing the  external  tear ;  and  3.  The  "crown- 
stitches." 

The  anterior  lacerations  were  all  repaired 
with   fine  plain  catgut.     The   tissues  here 


at  one  end  of  the  tear  and  tying  it.  This 
tied  end  is  used  as  a  tractor  and  the  suture 
continued  as  a  "half-hitch"  suture,  i.  e., 
after  every  bite  of  the  needle  the  catgut  is 
passed  underneath  the  last  stitch,  as  the 
tops  of  flourbags  or  bales  are  sewn.     The 


Page  Seventy-five 


suture  is  thus  continued  to  the  end,  leaving  The  aftercare  consisted  in  Iceepina-  the 

a  straight  wound  women  in  bed  for  ten  days.     No  douches 

All  these  eases  healed  up  by  primary  in-  were   given,   except   on   other  indications 

tent.on.  One,  m  which  plain  catgut  was  used  The  silkworm  gut  sutures  were  removed  in 


Fig.  10.     Illustrating  Laceeation   of  Perineum    (Chapter  14). 


va1inTpartTfc°"vound  "  T?^"  w    *^  '™T  '™  '°  f°"'""  ^^y^'  ^^  '^e  condition 

tors  .n?urpH  K    t^'        ^^'  J       I  sphincter  of  the  wound  demanded.    The  women  were 

chrom  c'ut  tried  TnTbffnl;-'"?  ™*  ^f'  "^'"^  ^"°^™d  up  after  ten  days  with  the 

heaS  pfrfectt                   "^    "'*''  '""''='''  ^"'"^l '?  P'^=!'  ='"<'  ^^out  the  house  a  day 

^            ^-  or  SO  before  their  removal. 


Page  Beventy-six 


REFEEENCES. 

1.  Gynaeciorum    hoc    est    de    Mulierum    turn 

Aliis  turn  Gravidarum,  etc.  Basileae  per 
T.  Guarinum.  1566-257,  chapter  xx.  Gy- 
naeciorum sive  de  mulierum  affectibus 
commentarii  Graecorum,  etc.  Basileae 
1586,  vol.  i,  chapter  xx,  p.  105.  Quoted 
by   Kelly-Noble. 

2.  AMBROISE  PARE.    Opera  Ambrosii  Parei 

regis  primarii  et  Pariensis  chirurgi,  etc. 
Parisiis.  J.  Dupuys,  1582.  Liber  xviii, 
chapter  xxvii,  p.  698.  IMd.  "The  Worker 
of  that  famous  Chirurgien  Ambroise 
Pare,  translated  out  of  the  Latin  and 
compared  with  the  French  by  Th.  John- 
son," etc.  London:  R.  Gates,  1649.  Liber 
xxiv,  chapter  xxvii,  p.  615.  Quoted  by 
Kelly-Noble. 

3.  GUILLEMAU,  J.     Les  Oeuvres  de  Chirur- 

gie,  etc.  Paris:  N.  Buon,  1612.  Livre 
iii,  chap,  vii,  p.  354.  Quoted  by  Kelly- 
Noble. 

4.  DIEFFENBACH,  J.  F.     Chirurgische  Eri- 

abrungen,  1829,  bd.  1,  p.  64.  Sur  la  rup- 
ture de  Perinee.  Jour.  Complementaire 
au  Dictionnaire  de  Science  Medicale, 
1830,  xxxviii,  pp.  193-206.  Ueber  die 
Zerreissung  des  Dammes  bei  Frauen, 
Medicinische  Zeitung,  1837,  bd.  vi,  p.  255. 

5.  METTAUER,  JOHN  P.     A  Case  of  Lacera- 

tion of  the  Perineum.  American  Journal 
of  the  Medical  Sciences,  1833,  vol.  xiii, 
p.  113. 

6.  ROUX.      Memoir   sur    la   restauration    du 

Perinee,  etc.  Gazette  Med.  de  Paris, 
1834.     Tome  ii,   p.   17. 

7.  IMd.        Clinique     chirurgicale.        L'Union 

Medicale,  1849,  vol.  iii,  p.  247. 

8.  BAYER,  W.     Cases  of  Ruptured  Perineum 

treated  successfully.  Edinh.  Med.  and 
Surg.  Jour.,  1823,  vol.  xix,  pp.  551-554. 

9.  CHURCHILL,    J.   M.      Case   of   Lacerated 

Perineum.  London  Med.  Repository, 
1824,  vol.  1,  pp.  464-468. 

10.  WILLIAMS,  C.     Case  of  Laceration  of  the 

Perineum.  London  Med.  and  Physic. 
Jour.,  1827,  vol.  iii,  pp.  101-102. 

11.  ALCOCK,   THOS.      On   the   Treatment   of 

Laceration  of  the  Perineum  in  Parturi- 
tion. London  Med.  and  Physic.  Jour., 
1820,  vol.  xliv,  pp.  193-197. 

13.  PRICKE,  J.  C.  G.     Episorrhaphie  ou  nou- 

velle  operation  pour  la  cure  de  prolapsus 
de  la  matrice.  Gaz.  Med.,  1835.  Tome 
iii,  p.   249. 

14.  NICK.       Beobachtung    der    vollkommenen 

Heilung  einer  noch  ganz  neuen  Damm- 
ruptur.  Med.  GorrespondenzMatt  des 
Wurttemdergischen  Aerztevereins,  Stutt- 
gart, 1838,  bd.  viii,  p.  301. 

15.  BROWN,  I.     Baker.     Diseases  of  Women, 

1854.  On  Rupture  of  the  Perineum  and 
its  Treatment,  etc.,  1855. 

16.  SAVAGE,  HENRY.     The  Surgery.     Surgi- 

cal Pathology  and  Surgical  Anatomy  of 
the  Female  Pelvic  Organs,  1870.  London, 
sec.  ed. 


17. 


18. 


19. 


20. 
21. 

22. 
23. 


EMMET,  T.  ADDIS.  A  Study  of  the  Eti- 
ology of  Perineal  Laceration  with  a  new 
method  for  its  proper  repair.  Transact. 
Amer.  Gynec.  Soc,  1883,  p.  198. 

WILLIAMS,  quoted  by  Hinchey.  Surgery, 
Gynecology  and  Obstetrics,  1907,  p.  155. 

McDonald,  ELLICE.  Mensuration  of 
the  Child  in  the  Uterus  with  New  Meth- 
ods.    /.  A.  M.  A.,  1906,  Dec.  15. 

MACOMBER.    Medical  Council,  1899,  Sept. 

HARVEY  DE  LA  MOTTE.  Stein  de  sig- 
norum  graviditatis  oetimatia. 

DUNCAN.    Am.  de  Gyn.,  1876,  Oct.,  p.  287. 

MORKOWSKY.  Zentr.  f.  Gyn.  1910,  xxxiv, 
p.  28. 


CHAPTER  XV. 

PREVENTION    OF    CATHETER    CYS- 
TITIS IN  THE  FEMALE. 

Introduction.— The  use  of  the  catheter  is 
as  old  as  the  Pyramids.  The  remains 
of  surgical  instruments  in  some  of  the 
recent  Egyptian  excavations  included 
among  them  bone  instruments  for  the 
catheterization  of  the  female  urethra.  It 
is  probable  that  since  that  time,  except  for 
surgical  cleanliness,  there  has  been  but 
little  improvement  in  the  technique  of 
catheterization.  The  catheter  is  still  thrust 
in  as  if  the  bladder  were  a  cyst  which  must 
be  punctured  with  a  trocar.  The  nurse 
grasps  the  instrument  with  a  firm  grip,  pre- 
pared to  stab  the  patient  if  she  moves  or 
attempts  to  escape.  After  several  inef- 
fectual jabs  and  thrusts,  the  catheter  is 
thrust  half  way  in  and  the  operator  stands 
up  in  triumph  to  allow  the  congested  blood 
to  escape  from  her  head  and  brushes  her 
hair  out  of  her  eyes.  In  some  hospitals, 
the  technique  varies.  In  one,  the  nurse 
was  required  to  wash  her  hands  as  for  a 
surgical  operation,  then  to  put  on  rubber 
gloves  and  gown.  She  must  then  take 
bichloride  and  five  gauze  wipes  and  rub  one 


Page  Seventy-seven 


over  each  labia  (being-  four  labia)  and  one 
over  the  meatus,  then  with  her  g-loves  well 
contaminated  and  the  parts  well  irritated 
by  the  bichloride,  she  thrusts  in  the  catheter. 

The  production  of  catheter  cystitis  de- 
pends upon  injury  to  the  tissues,  particu- 
larly to  the  mucous  membranes  in  the 
neighborhood  of  the  neck  of  the  bladder 
and  the  sphincter  muscle  of  the  bladder  and 
urethra.  Injury  to  the  lower  part  of  the 
trigone  is  particularly  prone  to  produce 
bladder  irritation. 

It  is  well  known  that,  in  operations  which 
involve  external  trauma  to  the  bladder,  such 
as  complete  hysterectomy,  there  is  a  very 
marked  tendency  toward  cystitis.  This  is 
most  frequent  in  operations  which  involve 
extensive  dissection,  such  as  cancer  opera- 
tions. There  is,  as  a  rule,  a  greater  dififi- 
culty  in  urinating  when  morphine  and 
atropin  have  been  used. 

After  labor  also,  there  is  sometimes  diffi- 
culty in  urinating.  This  is  more  fre- 
quent after  forceps  operations,  and  when 
the  anterior  vulvar  parts  have  been  injured 
or  torn. 

The  mere  presence  of  microorganisms 
in  the  urine  is  no  reason  for  cystitis, 
as  it  often  happens  that  the  urine  contains 
pus-forming  organisms  without  any  infec- 
tion. Injection  of  cultures  of  bacteria  will 
not  produce  cystitis  unless  trauma  is 
present. 

This  trauma  usually  comes  from  the  in- 
troduction of  the  catheter.  It  may  be  that 
there  is  in  addition  injury  from  the  opera- 
tion to  the  walls,  nerves  and  circulation  of 
the  bladder.  The  injury  of  the  catheter 
is  often  the  precipitating  factor. 

This  injury  to  the  urethra  and  trigone 
comes  in  several  ways.  First,  from  im- 
proper  catheters,   either   too   small   or  too 


large.  The  too  large  catheter  causes  in- 
jury from  difficulty  of  insertion  and  stretch- 
ing. The  very  small  catheter  causes  injury, 
because  its  small  size  makes  it  vegy  pliable 
and  difficult  of  insertion  and  too  much  is 
usually  inserted  into  the  bladder.  The  best 
size  of  catheter  is  one  which  will  fill  the 
urethra  without  stretching-  it.  This  is  best 
done  by  a  15  or  1 6  French. 

Injury  also  occurs  from  the  catheter  be- 
ing required  to  be  inserted  too  far  into  the 
bladder,  with  the  result  that,  when  the 
urine  is  drawn  off,  the  bladder  contracts 
down  upon  the  top  of  the  catheter  and  in- 
jures its  mucous  membrane.  In  addition 
to  this,  catheters  which  have  the  eye  in  the 
side  are  not  good,  because  as  the  urine  is 
drawn  off,  the  mucous  membrane  of  the 
bladder  is  drawn  into  the  eyelet  and 
may  be  injured.  This  is  particularly 
true,  when  the  bladder  is  lax  and  the 
urine  flows  off  faster  than  the  bladder  con- 
tracts. It  sometimes  shows  its  effect  upon 
the  flow  of  the  urine  when  the  "stammer- 
ing" or  "stuttering"  of  the  bladder  results 
from  the  mucosa  filling  the  eyelet  and  being 
suddenly  pulled  away  by  bladder  contrac- 
tions. The  flow  of  urine  comes  intermit- 
tently. 

Then  again  catheters  of  firm  material  as 
glass  do  not  adapt  themselves  to  the  shape 
of  the  urethra  and  so  put  the  parts  on 
stretch  and  cause  trauma.  The  urethra 
is  a  fairly  regular  curve  with  the  concavity 
upwards  and  most  glass  catheters  are 
straight  with  a  beak  or  nose.  They  cannot 
accommodate  themselves  to  the  urethra. 

To  overcome  these  defects,  I  use  a  rub- 
ber catheter  15  or  16  French  which  has  a 
hole  in  the  end  or  an  apical  aperture.  The 
catheter  will  not  distend  the  urethra  un- 
duly and  need  not  be  inserted  into  the 
bladder. 


Page  Seventy -eight 


The  urethra  is  of  varying-  length  in  dif- 
ferent women.  The  text-books  on  anatomy 
give  the  length  of  the  female  urethra  at 
6  cm.,  but  I  have  rarely  seen  a  urethra  of 
this  length.  The  length  as  measured  with 
the  catheter  varies  from  3.5  to  5.5  cm.  with 
an  average  of  about  4.5  cm.  It  is  obvious, 
therefore,  that  it  is  never  necessary  to  in- 
sert the  catheter  more  than  5.5  cm.  and 
usually  less.  For  this  reason,  I  have  the 
catheter  graduated  in  centimeters  and  use 


At  the  succeeding  catheterization,  the 
rubber  guard  is  moved  to  this  point  and  it 
is  then  assured  that  the  catheter  is  not 
thrust  in  too  far.  On  the  first  catheteriza- 
tion the  guard  is  placed  at  5.5  cm.,  so  that, 
until  the  urethra  is  properly  measured,  it 
is  sure  that  the  catheter  is  not  thrust  in  very 
far.  This  maneuvre  is  very  easy,  and  the 
rubber  guard  can  be  cut  from  any  tube  of  a 
proper  calibre. 


L        '         I z3 


Fig.     1.     Illtjsteating  Laceration  of  Perineum 


a  movable  piece  of  rubber  tubing  which 
fits  closely  over  the  catheter.  The  nurse  is 
instructed  to  measure  the  urethra  at  the 
first  catheterization.  This  is  done  by  pass- 
ing the  rubber  catheter  in  until  the  urine 
flows  freely.  It  is  then  gradually  with- 
drawn until  the  urine  ceases  to  run  and 
then  slowly  reinserted  until  the  flow  comes 
again.  This  point  is  measured  on  the  scale 
of  the  catheter  at  the  level  of  the  labia 
minora. 


Technique.— With  a  proper  instrument, 
it  is  necessary  to  know  how  to  insert  the 
catheter.  This  depends  upon  two  things: 
proper  lubrication  and  a  relaxation  of  the 
sphincter  of  the  bladder. 

Lubrication  is  necessary  for  the  insertion 
of  any  instrument  over  mucous  surfaces. 
No  one  would  think  of  inserting  a  male 
sound  or  a  rectal  tube  without  greasing 
them,  but  the  female  urethra  has  had  to 
suffer  for  its  shortness.     Here  greasing  is 


Page  Seventy-nine 


just  as  necessary  as  in  the  anus,  where  the 

passag-e  is  no  long-er. 

A  useful  lubricant  for  this  purpose  may  be 
made  by  boiling  Irish  moss  in  water.  Three 
ounces  of  Irish  moss  should  be  taken  and 
washed  in  running  water  for  a  half  hour.  It 
should  then  be  placed  in  two  pints  of  water 
in  a  saucepan  and  allowed  to  boil  over  a  rather 
slow  fire,  while  constantly  stirred.  If  it  is  not 
stirred,  it  had  better  be  put  into  a  double 
boiler,  otherwise  it  will  stick  to  the  bottom  of 
the  saucepan.  After  this  has  boiled  for  ten 
minutes,  it  should  be  taken  off  and  passed 
through  a  fine  wire  strainer,  such  as  is  used  in 
kitchens.  If  it  does  not  flow  readily  through 
the  strainer,  it  may  be  expressed  by  means  of 
rubbing  a  large  spoon  against  the  meshes  of 
the  wire.  This  strained  jelly  is  again  put 
upon  the  stove  and  sterilized  by  boiling  for 
one-half  hour  with  sufficient  water  added  to 
make  it  of  the  consistency  of  jelly.  After  one- 
half  hour  of  boiling,  the  jelly  is  taken  from 
the  stove  and  poured  into  lead  paint  tubes 
which  have  been  previously  boiled  with  their 
stoppers  in  another  vessel.  Before  the  jelly 
is  poured  into  the  tubes,  it  is  my  custom  to  add 
to  it  an  antiseptic,  such  as  eucalyptol  or  thymol. 
This  is  to  preserve  the  jelly. 

This  lubricating  jelly  is  useful  for  ex- 
aminations in  the  office.  If  it  is  desired  to 
make  the  jelly  clear  and  transparent,  it  is 
better  to  add  a  large  quantity  of  water, 
filter  throug-h  muslin  or  asbestos  fibre,  and 
later  evaporate  to  the  requisite  consistency. 
However,  this  is  not  necessary.  The  jelly 
is  cheap  and  costs  about  5  cents  a  quart. 
Irish  moss  is  commonly  used  in  this  country- 
by  brewers — to  lubricate  throats,  probably. 
The  jelly  may  be  put  into  lead  paint  tubes, 
w^hich  may  be  obtained  from  any  can  man- 
ufactory, or  into  small  wide-mouthed  glass 
bottles.  The  receptacles  must,  of  course, 
be  sterilized  before  using.  Enough  may 
be  made  at  once  to  last  throughout  the 
year.  Various  proprietary  preparations 
under  euphonious  names  may  be  obtained ; 
most  of  them  are  made  from  Irish  moss  or 
chrondrus.  Oil,  olive  or  paraffin,  makes  a 
good  lubricant,  but  has  the  disadvantage 
of  attacking  rubber. 

The  lubrication  must  be  applied  to  the 
catheter  and  to  the  urethra.     The  hands  are 


washed  and  the  left  forefinger  takes  up 
some  lubricant.  This  is  roughly  spread 
over  the  area  of  the  meatus,  coating  its 
parts  here  fairly  freely.  This  has  ^e  advan- 
tage of  making  a  coating  over  the  mucous 
membrane,  so  that,  if  the  catheter  does  miss 
the  meatus,  it  touches  the  lubricant.  No 
gauze  wipes  or  cotton  sponges  are  used. 
It  is  impossible  to  wipe  microorganisms  out 
of  the  urethra,  because  the  discharges  are 
only  driven  further  in. 

The  catheter  is  taken  in  the  right  hand 
which  remains  clean  and  well  lubricated 
with  the  Irish  moss  jelly.  The  labia  are 
held  apart  by  the  thumb  and  forefinger  of 
the  left  hand  which  rests,  palm  downward, 
on  the  symphysis. 

The  catheter  is  then  inserted  about  1.5 
cm.,  a  finger's  breadth,  and  held  there  with 
gentle  pressure.  The  patient  is  then  asked 
to  take  as  long  a  breath  as  it  is  possible  for 
her  to  take.  This  relaxes  the  sphincter  and 
the  catheter  slips  in  without  trauma. 

After  the  insertion  of  the  catheter  for  the 
first  1.5  cm.,  the  sphincter  immediately 
goes  into  reflex  spasm  and,  if  the  catheter 
is  forced  in,  the  spasm  becomes  firmer  and 
firmer.  It  is  necessary,  therefore,  for  the 
patient  to  turn  her  attention  to  the  contrac- 
tion of  some  other  antagonistic  set  of 
muscles,  the  contraction  of  which  releases 
the  involuntary  reflex  spasm  of  the 
sphincter  of  the  bladder  and  allows  the 
catheter  to  slip  in  almost  of  itself.  It  is 
very  easy  and  very  simple  and  is  based 
upon  the  same  principle  as  sw^allowing  the 
stomach  tube  or  bearing  down  in  the  pas- 
sage of  the  rectal  tube — relaxation  of  the 
sphincter. 

The  catheter  may  then  be  withdra\vti 
until  it  can  just  draw  off  the  urine  and  not 
enter  the  bladder,  as  is  shown  in  the  draw- 


Page  Eighty 


ing  of  the  catheter  with  the  special  aperture. 

When  the  bladder  contracts  during-  the 
withdrawal  of  urine  by  the  catheter,  there 
is  a  simultaneous  continuous  movement 
which  begins  slowly  and  increases  in  speed 
toward  the  end  of  micturition.  The  long- 
itudinal diameter,  however,  decreases  more 
and  quicker,  than  the  horizontal.  The  more 
powerful  longitudinal  muscles  would  ap- 
pear to  contract  more  quickly  and  more 
strongly,  than  the  circular  fibres.  The  re- 
sult of  this  is  that,  if  a  catheter  is  inserted 
too  far,  as  the  lateral-holed  catheter  must 
be,  the  bladder  wall  strikes  it,  before  the 
urine  is  all  out  of  the  bladder.  The  apical- 
orificed  catheter  avoids  this. 

To  prevent  the  necessity  of  catheteriza- 
tion, Frank^  has  recommended  the  injection 
of  15  to  20  c.  c,  of  glycerin,  which  he  calls 
a  laxative  for  the  bladder.  This  is  injected, 
when  urination  is  required.  This  is  effec- 
tive in  some  cases,  but  it  causes  some  irri- 
tation and  pain,  as  does  glycerine  on  any 
mucous  surface,  rectum  or  urethra.  Wald- 
stein-  uses  bougies  of  glycerine  90  per  cent, 
and  neutral  soap  9  per  cent,  for  the  same 
purpose.     Both   cause   a  little   irritation. 

An  injection  of  sterilized  paraffin  oil  is 
sometimes  effective  in  retention.  It  is 
harmless  and  may  be  injected  before 
catheterization.  The  syringe  should  be  a 
blunt-nosed  one  and  placed  against  the 
meatus  and,  while  the  patient  takes  long 
breaths  to  relax  the  sphincter,  gentle  pres- 
sure is  made.  In  this  way,  some  of  the 
oil  enters  the  bladder  and  a  catheter  is  un- 
necessary. The  glycerine  injections  some- 
times cause  too  much  irritation. 

1  Frank:  Zentralbl.  f.  Chirurgie,  1909  xxxviii, 
2. 

=Waldsteiii:  Gynaekol.  Rundschau,  1911,  Vol. 


If  catheter  cystitis  or  trigonitis  should 
occur,  the  sooner  treatment  is  instituted, 
the  easier  it  is  to  cure.  The  injection  of  a 
mild  silver  preparation  is  usually  all  that  is 
necessary.  A  one-fourth  of  one  per  cent, 
nitrate  of  silver  freshly  prepared  with  20 
per  cent,  glycerine  in  distilled  water  may 
be  used.  Nitrate  of  silver  is  less  irritating, 
provided  the  viscosity  of  the  solution  is 
greater  than  water.  The  thicker  the  solu- 
tion of  nitrate  of  silver,  the  slower  the  ac- 
tion and  the  less  irritating  the  effect.  For 
this  reason  glycerine  and  other  substances 
are  used.  Silver  nitrate  is  the  most  reliable 
of  the  silver  preparations,  provided  it  is 
freshly  prepared.  The  lack  of  irritation  of 
most  of  the  newer  silver  salts  and  prepara- 
tions depends  upon  their  greater  viscosity, 
slow  action,  and  weakness  of  effect  upon 
the  tissue. 

Treatment  should  be  begun  at  the  first 
signs  of  pain  and  pus  in  the  urine.  If  the 
nitrate  of  silver-glycerine  solution  is  not 
immediately  effective,  bladder  washing  may 
be  added. 

But  the  real  secret  of  the  abolition  of 
catheter  cystitis  is  its  prevention.  This  is 
best  done  by  a  proper  instrument  with  an 
aperture  in  the  end  which  allows  the  urine 
to  be  drawn  without  the  catheter  entering 
the  bladder.  The  catheter  should  be 
lubricated.  The  sphincter  of  the  bladder 
should  be  relaxed  before  the  catheter  passes 
it,  so  that  irritation  and  burning  of  the 
mucosa  does  not  occur.  This  is  best  done 
by  asking  the  patient  to  take  a  very  long 
breath  while  the  catheter  is  about  a  finger's 
breadth  in  the  meatus.  This  allows  the 
sphincter  to  relax  and  the  catheter  to  slip 
into  the  bladder.  In  this  way  trauma  is 
prevented,  and  without  trauma  catheter 
cystitis  does  not  occur. 


Page  Eighty-one 


CHAPTER  XVI. 
PLACENTA  PREVIA. 

Introduction. — Placenta  previa  is  one  of 
the  most  dangerous  complications  of  preg- 
nancy. Its  danger  to  the  child  is  not  less 
than  its  risk  to  the  mother.  More  than  half 
of  all  the  children  die  at  birth,  and  many 
survive  in  a  weakened  condition. 

The  frequency  of  placenta  previa  is 
variously  estimated.  From  reports  of 
clinics  collected  by  me  for  two  years  in 
183,389  labors,  placenta  previa  was  found 
once  in  160  labors.  Clinics,  however,  have 
more  than  their  proportion  of  these  cases 
and  the  rs^tio  of  occurrence  in  private  prac- 
tice is  probably  less. 

Etiology. — The  etiology  of  placenta  pre- 
via is  obscure.  One  known  fact  is  that  it 
is  much  more  frequent  in  multiparae.  My 
statistics  show  one  primipara  to  nine  multi- 
parae. The  more  children  the  greater  like- 
lihood of  placenta  previa.  The  rapidity 
with  which  the  labors  occur  also  increases 
the  probability  of  this  complication.  It  has 
been  suggested  that  changes  in  the  uterine 
wall  from  atrophy  or  inflammation  as  a  re- 
sult of  frequent  or  repeated  pregnancies 
predispose  toward  placenta  previa.  Such 
conditions  limit  the  amount  of  blood  going 
to  the  placenta  and  cause  it  to  spread  over 
a  larger  area  in  order  to  get  nourishment. 
This  is  borne  out  by  the  common  occurrence 
of  large  surface  and  thinness  of  the  placenta 
in  this  condition.  The  placenta  spreads 
down  and  overlaps  the  internal  os  and  so 
forms  placenta  previa.  The  mucosa  of  the 
isthmus  and  cervix  responds  less  actively 
than  that  of  the  fundus  to  the  decidual  re- 
action, so  that  placenta  is  required  to  be 
thin  and  expanded.     The  decidual  reaction, 


similar  to  that  of  tubal  pregnancy,  causes 
villi  to  grow  deeply  into  the  muscular 
bundles  of  the  isthmus  at  cervix,  often  to 
penetrate  almost  completely  the*' thickness 
of  the  wall. 

The  mucosa  of  the  isthmus  in  contrast  to 
that  of  the  cervix  shares  in  a  most  charac- 
teristic way  in  the  decidual  reaction,  al- 
though the  decidual  swelling  is  only  one- 
third  of  that  of  the  body  of  the  uterus.  On 
the  other  hand,  the  isthmus  more  resem- 
bles the  cervix  in  its  muscular  tissue  and  is, 
by  passive  stretching,  more  concerned  in 
the  course  of  pregnancy  in  the  enlargement 
of  the  ovisac  and  is  thus  transformed  into 
the  lower  uterine  segment.  The  isthmus 
normally  affords  nourishment  for  the  mem- 
branes ;  but,  in  placenta  previa,  the  implan- 
tation seriously  affects  the  condition  of  the 
wall.  The  embedding  of  the  placenta  has 
a  destructive  effect  penetrating  the  thin 
decidua  into  the  muscular  layer  in  such 
fashion  as  to  injure  the  wall  of  the  isthmus, 
reducing  its  elasticity  and  contractile  power. 

The  uterine  wall  thus  thinned  is  easily 
torn  and,  having  lost  much  of  its  elasticity, 
hemorrhage  is  common  both  before  and 
after  separation  of  the  placenta.  The  pla- 
centa may  be  so  adherent  as  to  be  separated 
with  difficulty  and  with  marked  loss  of 
blood.  The  cervical  tissue  is  readily 
lacerated  owing  to  its  increased  vascularity 
and  the  deep  implantation  of  the  villi. 

This  destructive  action  of  the  placental 
villi  is  more  marked  when  the  seat  of  the 
ovum  extends  into  the  cavity  of  the  cervix 
and  the  ovum  roots  itself  on  the  muscular 
tissue  there.  The  process  of  thinning  and 
weakening  of  the  lower  segment  of  the 
uterus  explains  the  proneness  to  laceration. 

It  is  possible  that  placenta  previa  may  be 
formed  by  fusion  of  the  decidua  reflexea 


Page  Eighty-two 


and  vera  over  the  internal  os ;  but  this  is 
probably  the  exceptional  mode  of  forma- 
tion, and  a  low  implantation  with  cleavage 
of  the  decidua  vera  and  obliteration  of  the 
OS  the  common  one. 

Mortality. — A  collection  of  cases  treated 
in  the  last  twenty  years  and  during-  the 
antiseptic  era  gives  8,888  cases  with  7.4  per 
cent,  maternal  mortality  and  55  per  cent, 
fetal  deaths,  considering  all  classes  of  pla- 
centa previa.  Complete  placenta  previa 
had  a  maternal  mortality  of  16  per  cent, 
and  a  fetal  mortality  of  72  per  cent.  In 
incomplete  (partial  or  lateral)  placenta  pre- 
via, there  was  a  maternal  mortality  of  5 
per  cent,  and  a  fetal  mortality  of  60  per 
cent.  Incomplete  placenta  previa  occurs 
three  times  as  frequently  as  does  complete. 
A  consideration  of  these  statistics  shows 
that  complete  placenta  previa  is  three  times 
more  fatal  to  the  mothers  than  is  incom- 
plete, and  that  approximately  two-thirds  of 
all  children  will  die,  although  complete  is 
also  more  dangerous  to  them.  The  ap- 
parent discrepancy  in  the  fetal  mortality 
percentage  of  the  incomplete  form,  being 
greater  than  the  combined,  is  due  to  the 
fact  that  all  reports  are  not  divided  into 
these  classes  as  may  be  seen  in  my  detailed 
paper  referred  to  in  the  footnote.^ 

A  comparison  with  the  results  obtained 
in  preantiseptic  days  shows  a  considerable 
drop  in  the  maternal  mortality  (23.6  per 
cent,  to  7.4  per  cent.)  ;  but  little  or  none  in 
the  fetal  mortality  (63  per  cent,  to  55  per 
cent). 

Many  children  die  soon  after  birth  in 
proportion  to  the  degree  of  their  prema- 


^  These  statistics  liave  been  detailed  at  length 
in  Surgery,  Gynecology  and  Obstetrics,  June, 
1911,  pp.  546-561,  and  there  has  been  added 
thereto  Cragin's  report  of  223  cases.  Am.  Jour, 
of  Obstetrics,  July,  1911. 


turity.  Mason  and  Williams  state  that,  of 
114  children  born  alive,  38  per  cent,  died 
within  a  few  days.  Of  the  children  born 
alive  at  full  term,  20  per  cent,  died  after- 
wards; of  children  born  alive  at  8  months, 
48  per  cent.,  and  of  children  born  alive  at 
7  months,  71  per  cent,  died  within  a  few 
days  of  delivery;  and,  as  only  36  per  cent, 
of  all  their  children  were  born  alive,  it  will 
be  seen  that  the  mortality  of  children  is  con- 
siderably increased  after  delivery.  Zweifel 
in  178  cases  of  placenta  previa,  found  that 
78  "children  were  born  alive  and  of  those 
weighing  less  than  2,500  gm.  (51^  pounds) 
only  nine  left  the  clinic  alive,  and  of  those 
weighing  more  than  that  amount,  39  left 
the  clinic  alive,  i.  e.,  41  per  cent,  of  those 
born  alive  dying  within  a  few  days. 
Couvelaire  also  shows  that  the  expectation 
of  life  depends  upon  the  maturity  of  the 
child;  thus  of  17  infants  weighing  less  than 
four  and  a  half  pounds  only  two  survived, 
whereas  of  19  weighing  more  than  six  and 
a  half  pounds,  ten  survived. 

It  may  be  seen  from  these  reports  that 
the  chances  of  life  of  the  child  are  very  pre- 
carious, not  only  from  the  dang-ers  of  ma- 
ternal hemorrhage,  malnutrition,  accidents 
of  delivery;  but  also  from  the  danger  of 
dying  after  delivery  from  prematurity, 
weakness  and  exhaustion.  The  danger  of 
death  to  the  child  is  increased  in  direct 
proportion  to  its  smallness  of  size  and  pre- 
maturity. 

Complications. — Hemorrhage  and  its  re- 
sults are  the  chief  danger  in  placenta  previa. 
This  bleeding  usually  occurs  some  time 
before  full  term  and  comes  on  as  a  dribbling 
of  blood  without  pain.  It  quite  often  occurs 
at  night  and  the  woman  is  awakened  by  a 
feeling  of  warmth  at  the  vulvar  parts.  The 
first  hemorrhage  is  not  usually  a  severe  one 
and  is  but  seldom  associated  with  straining 


Page  Eighty-three 


or  effort.  The  patient  does  not  as  a  rule 
go  into  labor  immediately  following-  the 
hemorrhage.  Of  Filth's  726  cases  treated 
by  midwives,  only  25  per  cent,  had  pain  im- 
mediately succeeding-  the  hemorrhage  and 
in  the  remaining  75  per  cent,  an  interval  of 
days,  weeks  or  months  occurred.  All  but 
three  of  the  women  applied  for  medical  aid 
before  delivery  on  account  of  the  hemor- 
rhage. Only  3  per  cent,  of  the  726  women 
had  no  hemorrhage  before  labor  pains  oc- 
curred. 

The  first  bleeding  usually  terminates 
spontaneously  and  leaves  the  woman  but 
little  weakened.  However  a  second  one  is 
not  long  in  coming  and  often  there  is  a 
persistent  dribbling,  so  very  weakening  to 
the  patient.  The  second  and  succeeding 
hemorrhages  are  more  likely  to  follow  upon 
straining  or  effort.  In  placenta  previa,  ap- 
proximately 70  per  cent,  of  all  deaths  are 
due  directly  to  hemorrhage  and  exhaustion, 
and  the  weakness  and  lack  of  resistance 
following  the  bleeding  is  indirectly  respon- 
sible for  many  who  died  from  infection,  air 
embolism,  shock,  uterine  rupture,  and  other 
causes.  In  Filth's  series,  there  were  141 
deaths,  of  which  98  died  from  hemorrhage 
and  a  large  percentage  of  the  rest  from  in- 
fection due  to  lessened  resistance.  The 
great  danger  is  hemorrhage  before,  during 
and  after  labor,  and  treatment  must  be 
directed  against  it. 

During  labor,  the  natural  straining  with 
labor  pains  is  one  of  the  main  dangers  in 
increasing  the  bleeding.  The  hemorrhage 
will  continue  after  the  cervix  has  been 
stretched  or  dilated  until  the  placenta  is  re- 
moved or  pressure  brought  to '  bear  upon 
the  cervical  vessels.  The  cervical  vessels 
do  not  pass  through  the  uterine  contractile 
tissue  but  go  directly  to  the  cervix  from 
the  uterine  arterv  and  vein. 


Postpartum  hemorrhage  also  occurs  in 
about  12  per  cent,  of  all  cases  based  upon 
recent  series.  This  is  more  common  in 
complete  placenta  previa  and  i^  probably 
due  to  the  weakening  and  destruction  of 
the  cervical  wall  due  to  the  imbedding  of 
the  placenta  in  that  part.  Hemorrhage 
after  delivery  often  comes  on  at  an  interval 
after  the  birth  of  the  hahy.  The  delivery 
of  the  child  causes  an  immediate  fall  in 
the  blood  pressure  of  the  mother,  but  this 
fail  is  soon  recovered  and,  when  the  pres- 
sure returns  to  its  former  level,  the  post- 
partum hemorrhage  occurs. 

In  cases  of  postpartum  hemorrhage,  the 
placenta  is  often  adherent  to  its  site  and  re- 
quires to  be  brought  away  by  manual  ex- 
traction. This  is  frequently  followed  by  a 
renewed  rush  of  blood.  In  four  of  Warren's 
14  cases  of  postpartum  hemorrhage  in  this 
condition,  the  placenta  was  adherent,  al- 
though there  was  no  hemorrhage  after  de- 
livery in  two  other  cases  of  adherent  pla- 
centa. 

There  is  also  danger  of  persistent  and 
severe  hemorrhage  from  cervical  lacera- 
tions. These  occur  readily  owing  to  the 
weakened  condition  of  the  cervical  wall,  its 
excessive  vascularity,  and  softness.  Often 
the  laceration  extends  so  high  that  it  can- 
not readily  be  sutured,  and  packing  is  not 
of  avail.  The  bleeding  is  often  only  drib- 
bling in  character,  but  may  be  free  and 
severe. 

Postpartum  hemorrhage  may  occur  in 
placenta  previa  treated  by  Caesarean  sec- 
tion if  the  cervix  has  been  dilated  by  labor 
pains  previous  to  operation  and,  while  the 
advisability  of  Caesarean  section  is  doubt- 
ful in  any  case,  it  is  positively  contrain- 
dicated  where  there  has  been  cervical  dilata- 
tion and  hemorrhage. 

Page  eigMy-four 


Laceration  of  the  cervix  is  the  most 
common  injury  in  placenta  previa.  It  is 
most  usually  due  to  delivery  of  the  head 
after  version  through  a  cervix  which  is  not 
fully  dilated.  The  friability  of  the  cervix 
from  placental  erosion  causes  laceration  to 
occur  with  readiness.  It  sometimes  ex- 
tends to  become  a  uterine  rupture  and 
cause  severe  hemorrhage.  Hauch  in  240 
cases  found  a  considerable  laceration  in  11 
with  two  deaths  from  hemorrhage. 

Laceration  may  also  be  caused  by  manual 
dilatation    of    the    cervix    by    Bonnaire's 
method  followed  by  version  and  extraction. 
Of   171   cases   reported  by  Bonnaire  after 
this  method,   the  cervix   was   lacerated   in 
20,  in  5  the  tear  extended  into  the  uterus 
and  in  2  involved  the  vaginal  wall.     Of  the 
patients  with  lacerations,  6  died.     Lacera- 
tion may  also  occur  from  the  elastic  rubber 
bag  or  hystereiu-ynter,  introduced  into  the 
cervix  to  stop  hemorrhage.     Of  144  cases 
treated  by  the  elastic  bag  by  Hauch,  there 
were  9  lacerations  and  in  the  majority  of 
these  a  weight  of  two  pounds  had  been  at- 
tached to  the  bag  to  hasten  dilatation.     In 
cases   where   the   bag  is    inserted    without 
any  weight,  laceration  is  not  so  common. 
The  weight  was  only  attached  to  the  bag 
in  those  cases  where  there  was  considerable 
hemorrhage  or  where  the  bag  did  not  com- 
pletely control  the  bleeding. 

Laceration  of  the  cervix  may  also  occur 
from  the  tearing  out  of  the  volsella  forceps 
applied  to  the  cervical  lip  for  traction  in  in- 
serting an  elastic  bag  or  in  packing  the 
cervix  with  gauze. 

Abnormal  position  of  the  fetus  is  a  not 
uncommon  complication  of  placenta  previa. 
The  situation  of  the  placenta,  occupying  as 
it  does  the  space  which  should  be  occupied 


by  the  child's  head,  forces  the  head  to  be 
elsewhere.  Miiller  in  his  statistics  found 
272  transverse  and  107  breech  positions  of 
1,148  cases.  There  was  thus  abnormal 
position  in  one-third  (33  per  cent.)  of  all 
cases.  This  malposition  is,  however,  not 
always  a  detriment  for  it  makes  version 
easier,  as  the  child  is  half  turned  already 
with  the  head  out  of  the  false  pelvis. 

The  placenta  is  often  adherent  and  this 
is  the  case  more  often  in  complete  placenta 
previa  on  account  of  the  more  extensive  in- 
filtration of  the  cervical  walls.  In  160 
cases  in  which  this  complication  was  noted, 
there  was  adhesion  to  a  greater  or  less  de- 
gree in  67  cases  (42  per  cent.).  The  pla- 
centa frequently  requires  manual  extrac- 
tion, even  when  broken  into  fragments  by 
thrusting  the  hand  through  it  to  do  version 
and  breech  extraction. 

Plural  pregnancy  is  more  common  in 
placenta  previa  than  in  the  ordinary  run  of 
cases.  Winckel  states  that,  in  his  expe- 
rience, twins  are  four  times  as  common  in 
this  condition  as  customarily.  Warren 
found  twins  twice  in  94  labors  where  the 
usual  ratio  is  i  to  80  labors.  In  these  cases, 
the  twins  are  usually  weak. 

Diagnosis. — Hemorrhage  is  usually  the 
first  sign  of  placenta  previa  and  comes  on 
as  a  rule  without  straining  or  excessive 
effort.  It  rarely  appears  before  the  seventh 
month;  but  is  more  frequent  during  the 
last  month  of  pregnancy.  This  hemorrhage 
as  a  rule  comes  before  the  labor  begins ;  in 
about  75  per  cent,  of  cases,  there  is  an  in- 
terval between  the  first  hemorrhage  and 
labor.  Very  few  cases  have  no  bleeding  at 
all  before  labor  pains  begin.  This  first 
bleeding  usually  terminates  spontaneously. 
Examination  of  the  woman  at  this  time 
usually  shows  a  cervix    which    is    dilated 


Page  EigMy-five 


sufficiently  to  insert  a  finger  and  feel  within 
the  cervix  the  roughened  outside  surface 
of  the  placenta  covering  the  os.  The  abrupt 
margin  of  the  placenta  may  sometimes  be 
felt  through  the  abdominal  wall  above  the 
symphysis  and  at  the  posterior  vaginal 
fornix  the  rear  margin  may  be  palpated  by 
the  examining  finger. 

When  the  cervix  will  not  admit  one 
finger,  the  placenta  may  be  felt  between  the 
fetal  head  and  the  finger  as  a  soft  interven- 
ing cushion.  Attempts  to  produce  ballotte- 
ment  drive  this  cushion  against  the  head. 
The  cervix  is  usually  shorter  and  softer 
than  in  normal  pregnancy.  Manipulations 
of  the  cervix  produce  bleeding  easily.  It 
should  be  remembered  that  malposition  is 
associated  with  placenta  previa  in  approx- 
imately one-third  of  all  cases.  When  the 
placenta  is  inserted  in  the  cervix  the  lip  of 
the  OS  protrudes  and  the  cervix  ballooning 
often  resembles  an  abortion  impacted  in  the 
cervix.  Sometimes  the  cervix  is  friable, 
but  if  it  is  open,  crumbling  masses  may  be 
felt,  which  will  usually  bleed  at  touch. 

Treatment. — The  treatment  of  placenta 
previa  must  be  considered  in  general  and 
then  as  to  the  various  types  of  the  disease. 

The  indications  to  be  met  are  the  control 
of  hemorrhage  and  the  delivery  of  the  child 
without  traumatism,  mutilation,  or  delay. 

In  no  condition  in  obstetrics  is  delay  so 
dangerous  to  mother  and  child  as  in  placenta 
previa.  Delivery  should  follow  the  first 
hemorrhage.  The  only  exception  to  this 
rule  is  where  the  patient  can  be  put  to  bed 
in  a  hospital  and  carefully  watched.  Delay 
is  then  permissible  as  long  as  the  pulse  is 
below  100,  and  the  mother  and  child  in  good 
condition.  Delay  is,  even  then,  not  without 
danger,  but  often  the  intense  desire  for  a 
live  child  will  excuse  the  chances  taken. 

The  improvement  in  results  comes  not  so 


much  from  any  •  method  of  treatment  as 
from  early  delivery,  and  early  delivery  is 
as  advantageous  to  the  child  as  to  the 
mother.  Delivery  should  immediately  fol- 
low upon  complete  dilatation  of  the  cervix, 
but  delivery  should  be  without  traumatism. 

The  danger  of  hemorrhage  is  increased 
by  strong  internal  contractions  and  the 
probability  of  cervical  laceration  is  much  in- 
creased. The  ideal  course  in  placenta 
previa  is  dilatation  of  the  cervix  with  mild 
labor  pains  and  little  natural  straining.  For 
this  reason  if  pains  are  strong,  particularly 
if  an  elastic  bag  is  inserted,  it  is  usually 
well  to  control  them  by  a  hypodermic  of 
morphine,  gr.  Ye  to  %,  and  atropin,  gr. 
Vioo-  Atropin  is  a  useful  uterine  sedative 
and  has  a  distinct  effect  in  preventing  severe 
contractions.  As  long  as  the  membranes 
are  unruptured,  the  greatest  safety  of  the 
mother  lies  in  prohibiting  strong  pains  or 
straining. 

If  hemorrhage  is  severe,  hypodermoclysis 
or  venous  transfusion  should  be  done.  It 
should  be  remembered  that  normal  saline 
solution  does  not  consist  of  one  dram  of 
sodium  chloride  to  a  pint  of  water;  but 
other  salt  should  also  be  included.  Evil  re- 
sults have  been  reported  from  using  sodium 
chloride  alone.  A  useful  formula  is  as  fol- 
lows: Sodium  chloride  9.0  gm.,  calcium 
chloride  o.i  gm. ;  potassium  chloride  0.25 
gm.  to  one  liter  of  water. 

The  choice  of  anesthetic  is  of  considerable 
importance.  Anesthesia  is  not  as  a  rule 
required  for  the  insertion  of  the  elastic  bag ; 
but  when  version  and  extraction  or  other 
operations  must  be  done,  anesthesia  is 
necessary.  Chloroform  should  be  given 
with  great  care  in  the  presence  of  hemor- 
rhage, particularly  if  that  hemorrhage  is 
sudden.  I  have  come  to  fear  it  greatly  in 
placenta  previa  and  always  substitute  ether 

Page  Eighty-six 


where  possible.  The  pregnant  woman  does 
not  bear  ether  as  well  as  chloroform ;  they 
are  apt  to  be  troubled  with  mucus  and 
bronchial  irritation,  possibly  due  to  laryn- 
geal congestion. 

Still  the  danger  of  sudden  collapse  and 
shock  is  so  great  in  placenta  previa  that 
ether  should  be  the  anesthetic  of  choice. 

It  is  important  to  hasten  to  arrest  the 
hemorrhage  and  then  deliver  the  woman 
without  haste  and  without  force.  Because 
it  is  important  to  hasten  to  arrest  the  hemor- 
rhage, it  does  not  follow  that  delivery 
should  be  hastened. 

In  considering  the  treatment  of  complete 
placenta  previa,  it  should  be  remembered 
that  we  have  to  do  with  a  disease  which 
under  the  best  clinic  auspices  kills  one  in 
six  of  the  mothers  and  about  three  out  of 
four  babies.  The  greatest  danger  to  both 
mother  and  child  is  from  hemorrhage  and 
to  it  must  the  treatment  be  directed.  The 
chances  of  saving  a  child  are  so  small  that 
the  mother's  risk  must  not  be  increased  on 
that  account.  Delay  in  delivery  after  the 
first  hemorrhage  but  weakens  the  child  and 
increases  the  maternal  risk. 

The  child  is  premature  in  60  per  cent, 
of  all  cases  and  death  after  a  few  days 
occurs  in  from  15  to  71  per  cent,  of  all 
babies,  depending  upon  the  degree  of  pre- 
maturity, so  that  the  chances  of  life  for  the 
child  are  not  great  in  complete  placenta 
previa. 

The  danger  from  hemorrhage  is  not  only 
from  collapse  after  one  or  two  hemor- 
rhages, but  from  sudden  shock  after 
repeated  small  hemorrhages.  All  sur- 
geons know  how  little  resistance  those  pa- 
tients have,  who  suffer  from  repeated 
hemorrhages  as  from  uterine  fibroids,  and 
placenta  previa  cases  are  no  exception  to 
the  rule. 


For  these  reasons  then,  the  indication  for 
treatment  of  complete  placenta  previa  is 
immediate  stoppage  of  the  hemorrhage  with 
little  consideration  for  the  life  of  the  child. 
When  the  cervix  is  fully  dilated,  the  in- 
dication is  clear.  Immediate  delivery  of 
the  child  controls  the  hemiorrhage  and 
offers  the  child  the  best  chance  of  life.  De- 
livery may  then  be  done  by  Braxton-Hicks' 
version  and  immediate  breech  extraction. 
This  should  be  done  carefully  and  slowly 
so  as  not  to  cause  any  mutilation  of  the 
cervix  or  perineum. 

It   is   usually   well,   if   condition    of   the 
patient    allows,    to    dilate  the  vagina  and 
stretch  the  perineum  with  the  hand.     This 
makes   the    difficulty   of   breech   extraction 
much     less.     If    the    placenta    completely 
covers  the  dilated  cervix,  it  is  better,  when 
thrusting  the  fingers  into  the  uterus  to  do 
the  bimanual   version,  to  attempt  to  pass 
two  fingers  around  the  anterior  lobe  of  the 
placenta  under  the  symphysis  rather  than 
through  the  centre  of  the  placenta.     The 
risk  to  the  child  is  increased  by  piercing  of 
the  placenta  by  thrusting  the  hand  through 
the  centre  and,  as  the  geometric  centre  of 
the  placenta  hardly  ever  coincides  with  the 
centre  of  the  cervix,  two  fingers  can  usually 
be  passed  around,  and  they  are  sufficient  to 
do  the  bimanual  version.     In  case  the  edge 
of  the  placenta  cannot  be  passed,  the  ob- 
stetrician can  always  fall  back  upon  pierc- 
ing the  placenta  although  after  this  proce- 
dure hardly  a  single  child  survives,  so  it  is 
useless  to  try  to  hasten  the  extraction  of 
such  a  child. 

Extraction  should  immediately  follow 
version  only  when  the  os  is  fully  dilated  or 
nearly  so,  because  of  the  danger  of  cervical 
lacerations  and  uterine  rupture. 

When  in  central  or  complete  placenta 
previa,  the  os  is  undilated,  immediate  control 


Page  Eighty-seven 


of  the  hemorrhag-e  is  more  difficult.  The 
amount  of  the  dilatation  of  the  cervix  is  not 
sufficient  to  allow  the  passage  of  the  fetal 
head  and  the  bleeding-  must  be  controlled 
until  the  proper  dilatation  is  obtained.  This 
control  of  hemorrhage  may  be  obtained  in 
one  of  three  ways:  (i)  by  Braxton-Hicks' 
version,  bringing  down  one  foot  so  that  the 
fetal  body  acts  as  a  tampon  and  delayed 
extraction;  (2)  by  the  use  of  the  inflatable 
elastic  bag  of  Champetier  de  Ribes;  or  (3) 
by  tamponage  of  the  cervix  with  gauze. 

If  the  child  is  dead  or  premature,  version 
with  delayed  extraction  answers  well.  It 
usually  sacrifices  the  child,  but  in  most 
cases  controls  bleeding.  If  the  cervix  is 
half  dilated,  version  with  delayed  extrac- 
tion is  commonly  successful,  because  the 
cervix  is  usually  soft  and  the  half  breech 
causes  dilatation  within  a  short  time. 

If,  however,  the  child  is  alive  and  the  os 
small  or  not  readily  dilatable,  the  choice  of 
treatment  must  be  among  the  three,  with 
the  preference  to  the  elastic  bag,  where  pos- 
sible. 

The  elastic  bag  or  hysteurynter  gives 
good  results,  provided  certain  conditions 
are  observed.  First  the  operator  must  be 
skillful  in  its  use  and  observe  all  antiseptic 
precautions.  The  danger  of  infection  is 
said  to  be  increased  but,  in  246  cases  treated 
by  the  inflatable  bag,  Hannes  found  only 
0.9  per  cent,  mortality  from  infection;  so 
that  it  is  evident  that  in  good  hands  the 
mortality  from  infection  is  even  less  than 
in  other  forms  of  treatment.  Second,  the 
bag  must  be  introduced  within  the  ovum. 
If  the  bag  is  placed  outside  the  membranes, 
the  maternal  mortality  is  very  much  greater, 
as  is  shown  by  the  report  of  Hauch  of  96 
cases,  in  which  the  bag  was  introduced  out- 
side the  ovum  with  a  mortality  of  15.6  per 
cent.,  and  of  48  cases  in  which  the  bag  was 


introduced  within  the  ovum  with  a  mortality 
of  2.1  per  cent. 

In  cases  where  the  placenta  does  not  com- 
pletely cover  the  half  dilatated  «s,  the  in- 
troduction of  the  bag  within  the  membranes 
is  comparatively  easy;  but  when  the  pla- 
centa completely  covers  the  os  and  the  bag 
cannot  be  passed  around  the  anterior  lobe, 
it  becomes  a  question  whether  it  is  better 
to  pierce  the  placenta  with  the  bag  or  to 
do  a  bimanual  version  by  the  insertion  of 
two  fingers  aided  by  outside  manipulations 
with  delayed  extraction  of  the  child  after 
the  foot  had  been  pulled  down. 

The  choice  between  these  two  methods 
under  such  circumstances  will  depend  upon 
the  condition  of  the  mother  and  the  child. 
The  bag  treatment  improves  the  chances  of 
the  child;  but  if  the  child  is  dead  or  pre- 
mature, this  does  not  have  weight.  A  pre- 
mature child,  being  small  with  a  soft  cra- 
nium, is  not  so  likely  to  tear  the  cervix.  If 
the  mother  is  in  great  weakness  from 
hemorrhage,  delayed  extraction  after  ver- 
sion will  probably  stop  the  hemorrhage 
more  quickly,  as,  with  the  bag  after  the  os 
is  dilated,  delivery  must  still  be  effected. 

Altogether  the  rule  may  be  laid  down 
that,  when  the  os  is  partially  dilated  with  a 
live  child,  the  bag  treatment  offers  the  best 
results  when  it  can  be  introduced  into  the 
ovum  and  when  urgent  symptoms  are  not 
present.  In  387  cases  where  the  bag  alone 
was  used  and  introduced  into  the  ovum 
where  possible,  the  maternal  mortality  was 
5  per  cent.  The  most  successful  of  this 
number  was  Hannes'  143  cases  treated  by 
the  bag  alone  with  no  deaths  from  hemor- 
rhage, although  there  were  8  deaths  from 
other  causes,  as  previous  infection,  eclamp- 
sia, etc.  The  hystereurynter  reduces  the 
mortality  of  the  children  from  70  per  cent, 
to   30  per  cent,   according  to  figures   col- 


Page  Eighty-eight 


lected  from  these  series.  The  greater  hope 
of  Hfe  that  the  elastic  bag  or  hystereurynter 
gives  the  fetus  may  be  judged  from  Thies' 
report  of  the  results  from  Bumm's  clinic. 
Taking  all  births  into  consideration,  the 
fetal  mortality  was  as  follows :  spontaneous 
delivery,  20  per  cent. ;  vaginal  gauze  plug- 
ging, 33  per  cent. ;  combined  version  with 
slow  extraction,  80  per  cent. ;  combined  ver- 
sion with  rapid  extraction,  64  per  cent. ; 
vaginal  Caesarean  section,  50  per  cent. ; 
hystereurynter  or  elastic  bag,  14  per  cent. 

Combined  version  with  delayed  extrac- 
tion is  very  fatal  to  the  child  and  should  be 
restricted  as  much  as  possible  to  urgent 
cases  where  the  mother's  condition  de- 
mands immediate  control  of  the  hemor- 
rhage. If  the  interest  of  the  mother  alone 
is  to  be  considered,  Braxton-Hicks'  version 
and  delayed  extraction  remain  the  safesc 
method  if  the  cervix  is  partially  dilated. 

There  are  certain  necessities  for  success- 
ful treatment  by  the  hystereurynter.  The 
bag  must  be  of  large  size,  as  big  as  a  nor- 
mally large  fetal  head.  It  should  measure 
10  to  12  cm.  in  diameter  and  contain  from 
500  to  600  cm.  (about  20  oz.).  The  bag 
treatment  in  this  country  has  achieved  a 
bad  reputation  because  the  small  de  Ribes 
bag,  intended  for  induction  of  labor,  has 
been  used  and  inserted  outside  the  ovum. 

The  bag  should  be  inserted  within  the 
membranes  with  a  special  forceps  for  the 
purpose,  and  with  antiseptic  precautions. 
The  bag  may  be  boiled  and  kept  ready  for 
use  in  glycerine  which  will  preserve  it,  as 
rubber  is  apt  to  crack  and  spoil  if  kept  dry. 
It  may  be  boiled  with  the  glycerine  in  a 
large  preserve  jar  and  the  jar  wrapped  in 
a  sterile  towel  ready  for  use. 

The  bag  remains  in  position  for  3  to  5 
hours  as  a  rule.  If  the  control  of  the 
hemorrhage  is  good,  no  weight  need  be  at- 


tached ;  but,  if  the  bleeding  is  not  perfectly 
stopped,  a  2  lb.  weight  may  be  attached  on 
a  cord  running  over  a  pulley,  as  in  fracture 
extension,  on  the  end  of  the  bed.  If  the 
weight  is  attached,  a  stout  elastic  band 
should  intervene  between  the  bag  and  the 
cord  of  the  weight.  In  this  way,  sudden 
pull  on  the  uterus,  caused  by  the  patient 
drawing  away  from  the  weight,  is  avoided 
and  the  danger  of  cervical  laceration  is  les- 
sened. The  weight  should  only  be  attached 
to  those  cases  where  there  is  considerable 
hemorrhage  or  labor  is  unduly  prolonged. 
After  the  use  of  dilating  bags,  the  operator 
should  be  necessarily  cautious  in  doing  ver- 
sion and  breech  extraction,  as  there  is 
danger  of  uterine  rupture. 

The  advantage  of  the  bag  is  that  com- 
pression is  applied  directly  to  the  placenta 
forcing  it  back  into  its  place.  Tamponage 
on  the  contrary  forces  the  placenta  away 
from  its  bed  and  tends  to  increase  hemor- 
rhage. The  bag  acts  as  a  tampon,  as  a 
labor  promoting  element,  and  as  a  gentle 
dilating  force. 

Cervical  tamponage  is  a  makeshift 
method,  only  to  be  resorted  to  when  the 
bags  are  not  at  hand.  It  is  often  ineffectual 
in  controlling  hemorrhage  and  of  little  use 
as  a  cervical  dilator.  The  percentage  of 
infection  after  packing  is  larger  than  after 
any  other  method.  It  is  useful  when  the 
cervix  is  partially  dilated  and  hemorrhage 
must  be  controlled  until  other  measures 
are  undertaken. 

Antiseptic  moist  gauze  should  be  used 
and  it  is  well  if  the  antiseptic  is  a  styptic 
also. 

The  gauze  may  be  left  until  the  cervix  is 
sufficiently  softened  and  dilated  to  allow  a 
bag  to  be  inserted  or  bimanual  version  to 
be  done.  The  packing  is  not  effective  un- 
less  the  gauze  is  packed  well  within  the 


Page  Eighty-nine 


cervix  and  up  against  the  placenta  and  the 
vagina  packed  full  of  gauze  also  in  order 
to  afford  support  and  counter  pressure. 
The  gauze  should  be  moist  as  it  then  may- 
be packed  more  firmly  and  care  should  be 
taken  not  to  bruise  the  vaginal  mucosa  in 
the  manipulation.  A  vaginal  speculum 
should  be  introduced  with  the  patient  upon 
a  table  and  in  a  good  light,  the  cervix  should 
be  caught  and  steadied  with  a  bullet  forceps 
and  the  gauze  packed  firmly.  The  patient 
should  be  put  to  bed  and  watched  carefully 
for  evident  bleeding  or  signs  of  concealed 
hemorrhage. 

JMaison,  in  a  report  of  154  cases  treated 
by  various  methods,  had  the  highest  mor- 
tality, 25  per  cent.,  with  tamponage  and 
lost  70  per  cent,  of  the  children.  The 
deaths  were  from  bleeding  and  infection. 

Other  methods  do  not  show  as  good 
results  as  the  ones  referred  to.  Bon- 
naire's  method  of  bimanual  dilatation 
of  the  cervix  and  immediate  delivery 
has  a  higher  mortality  than  the  previous 
methods.  He  has  reported  171  cases  treated 
by  this  method  with  a  mortality  of  18  per 
cent.  The  disadvantages  of  the  method 
are  the  amount  of  time  required  to  dilate 
the  cervix,  twenty  minutes  to  one  hour  in 
Bonnaire's  hands,  with  constant  loss  of 
blood,  the  danger  of  laceration  of  the 
cervix,  and  the  difficulty  of  completely  dilat- 
ing the  cendx  so  that  the  head  may  come 
through  without  traumatism. 

Steel  dilators  after  the  type  of  Bossi's 
instrument  are  very  dangerous  and  only  of 
use  to  dilate  the  cervix  sufficiently  to  allow 
version  to  be  done  or  to  insert  a  bag.  A  de 
Ribes  bag  may  usually  be  inserted  through 
a  cervix  admitting  two  fingers,  and  to  obtain 
this  amount  of  dilatation  the  Goodell  two- 
pronged  dilator  does  as  well  as  the  more 
complicated  and  expensive  instrument  of 
Bossi. 


Caesarean  section,  much  vaunted  of  re- 
cent years  by  surgeons,  is  not  favored  by 
obstetricians.  Holmes'  collection  of  Caesa- 
rean sections  for  placenta  prevfe  gave  a 
maternal  mortality  of  20  per  cent,  and  an 
ultimate  fetal  mortality  of  64  per  cent. 
Little  encouragement  here  to  advocate  the 
operation.  Jewett,  in  a  later  paper,  col- 
lected 95  cases,  not  including  Holmes'  col- 
lection, wtih  a  maternal  mortality  of  11.5 
per  cent,  and  a  direct  fetal  mortality  of  34 
per  cent.,  the  ultimate  fetal  mortality  of 
children  dying  in  the  puerperium  not  being 
stated.  The  combined  series  give  a  ma- 
ternal mortality  in  125  cases  of  13.6  per 
per  cent. 

The  ease  with  which  Caesarean  section 
can  be  done  deludes  operators  into  the 
belief  that  it  is  a  simple  operation  and 
without  mortality ;  but  the  facts  remain  that 
the  mortality  of  all  classes  of  Caesarean 
section  is,  in  3,000  collected  cases,  7  per 
cent.  How  much  greater  will  the  dangers 
be  in  placenta  previa  where  the  patient, 
weakened  by  hemorrhage  and  contaminated 
by  examinations,  is  unfit  to  stand  such  a 
radical  surgical  procedure.  To  treat  these 
cases  by  Caesarean  section  is  but  to  add  an- 
other greater  danger  to  that  already  exist- 
ing. 

The  only  excuse  for  a  Caesarean  section 
in  any  condition  is  to  save  a  living  child 
and,  if  there  is  a  direct  fetal  mortality  of  at 
least  34  per  cent,  with  a  probable  ultimate 
mortality  one-fourth  greater,  a  living  child 
will  hardly  be  obtained  in  as  many  cases  as 
in  the  bag  treatment  and  the  safe  method 
of  version  and  delayed  extraction  will  save 
more  mothers.  It  is  doubtful  whether  the 
125  cases  with  13.6  per  cent,  mortality  rep- 
resents the  true  estimate  of  mortality,  as 
no  large  clinic  statistics  have  yet  been  re- 
ported and,  with  isolated  cases,  it  is  human 


Page  Ninety 


nature  to  report  successes  and  allow  failures 
to  be  forgotten. 

When  Caesarean  section  is  not  done  until 
the  end  of  the  period  of  dilatation,  there  is 
no  security  against  a  fatal  after  hemor- 
rhage, for,  by  that  time,  the  insertion  of  the 
placenta  in  the  isthmus  or  cervix  has  already 
been  stretched  and,  with  defective  contrac- 
tion of  this  segment  of  the  uterus,  hemor- 
rhage is  likely  to  follow.  The  hemorrhage 
comes  mainly  from  the  lacerated  vessels  in 
the  upper  part  of  the  cervix  and,  with  a 
Caesarean  wound  in  the  uterus,  this  would 
be  difficult  to  control  by  gauze  packing  or 
other  means. 

Vaginal  Caesarean  section  has  been  ad- 
vocated in  placenta  previa  with  an  undilated 
cervix.  Bumm  was  its  most  weighty  ad- 
vocate; but  now  he,  Sigwart  says,  has 
abandoned  the  operation.  The  amount  of 
hemorrhage  is  greater  from  a  cut  wound 
than  from  a  torn  one  and,  in  these  incisions 
of  vaginal  Caesarean  operation,  the  bleed- 
ing is  sometimes  severe  and  difficult  to  con- 
trol. If  the  placenta  is  situated  posteriorly, 
it  may  be  possible  that  anterior  hysterot- 
omy may  be  of  value,  but  it  is  difficult  to 
decide  when  this  condition  occurs.  Also, 
if  the  placenta  is  posteriorly  situated,  the 
elastic  bag  may  be  passed  around  the  an- 
terior lobe. 

Incisions  into  the  cervix,  when  the  os  is 
not  fully  dilated  are,  however,  occasionally 
of  use,  although  they  need  not  go  so  far  as 
to  include  the  surface  of  the  uterus  above 
the  vaginal  vaults. 

In  the  treatment  of  the  incomplete  form, 
the  mainstay  of  treatment  is  the  elastic  bag. 
Its  advantages  are  that  it  can  be  easily  in- 
serted and  it  controls  the  hemorrhage.  The 
placenta,  not  covering  the  os  completely, 
does  not   obstruct   its   passage;   the   mem- 

Page  Ninety-one 


branes  are  easily  ruptured  and  the  elastic 
bag  may  be  inserted  within  the  membrane, 
much  reducing  the  mortality. 

Version  and  breech  extraction  must  be 
reserved  for  those  cases  of  incomplete  pla- 
centa previa  in  which  the  os  is  fully  dilated 
with  unruptured  membranes  or  urgency  of 
delivery  is  demanded.  The  greater  possi- 
bility of  obtaining  a  living  child  in  incom- 
plete placenta  previa  renders  it  expedient 
that  all  possible  means  should  be  taken  to 
this  end. 

When  the  insertion  of  placenta  is  high  in 
the  uterus  and  the  membranes  present  at 
the  OS,  the  hemorrhage  may  sometimes  be 
controlled  and  labor  hastened  by  rupture 
of  the  membranes.  This  gives  the  best 
chance  of  a  live  child. 

The  treatment  by  rupture  of  the  mem- 
branes alone,  however,  should  be  confined 
to  mild  cases  with  a  high  insertion  of  the 
placenta.  The  main  reliance  in  the  treat- 
ment of  incomplete  placenta  previa  should 
be  the  large  elastic  bag,  lo  to  12  cm.  in 
diameter  and  with  a  capacity  of  500  c.  c.  of 
water.  Version  and  breech  extraction 
should  be  reserved  for  those  urgent  cases 
with  a  fully  dilated  cervix  and  much  bleed- 
ing. 

The  dangers  of  placenta  previa  by  no 
means  cease  with  delivery  of  the  child,  but 
in  a  large  proportion  of  cases,  hemorrhage 
occurs  after  labor.  This  bleeding  does  not 
as  a  rule  occur  immediately  after  delivery, 
because  of  the  fall  in  blood  pressure  coin- 
cident with  the  birth  of  the  child;  but 
usually  takes  place  within  an  hour.  This 
delay  of  the  hemorrhage  makes  it  of  a  most 
insidious  and  dangerous  character.  A  very 
large  percentage  of  all  deaths  in  placenta 
previa  are  due  to  this  form  of  hemorrhage. 
In  Hammer's  series,  three  of  eight  deaths 
were  from  postpartum  hemorrhage  due  to 


atony  of  the  uterus.  In  Warren's  series  of 
ninety-four  cases,  postpartum  hemorrhage 
was  present  in  15  per  cent,  and,  of  six 
deaths  in  all,  two  were  from  this  cause. 

It  is,  therefore,  necessary  to  take  meas- 
ures to  prevent  the  occurrence  of  this 
hemorrhage.  A  dose  of  one  of  the  good 
preparations  of  ergot  should  be  given  hy- 
podermatically  immediately  after  delivery 
of  the  child.  It  is  better  to  use  one  of  the 
physiologically  tested  preparations,  for 
much  of  the  ergot  upon  the  market  is  inert. 
Pituitrin,  an  extract  of  the  pituitary  body, 
is  very  efficient  in  stimulating  the  uterus  to 
contract  and  has  been  used  with  good  suc- 
cess by  Foges  and  Hofstatter  in  sixty-five 
cases  of  postpartum  hemorrhage.  The 
uterus  contracts  firmly  and  remains  in  that 
condition  for  some  time.  It  promises  to  be 
useful  in  placenta  previa. 

The  question  of  uterine  packing  with  an- 
tiseptic gauze  to  prevent  hemorrhage  imme- 
diately after  delivery  is  an  important  one. 
If  a  patient  is  in  a  hospital  where  she  can 
be  carefully  and  minutely  watched,  and  if 
the  uterus  has  contracted  well,  uterine  pack- 
ing may  not  be  necessary ;  but  if  the  woman 
is  delivered  in  a  house  where  the  prepara- 
tion for  packing  would  involve  some  delay, 
or  if  the  woman  is  weak  from  bleeding  and 
can  spare  no  more  blood,  uterine  packing 
should  be  done  as  a  prophylactic  against 
hemorrhage. 

In  other  words,  the  uterus  should  be 
packed  with  gauze  to  prevent  hemorrhage, 
or  preparations  should  be  made  so  it  can 
be  done  instantly  in  case  hemorrhage 
should  begin.  After  delivery  in  placenta 
previa,  no  patient  should  be  left  without 
constant  medical  supervision  for  several 
hours  after  delivery. 


EEFEEENCES. 


1.     MAISON   and   WILLIAMS.      Boston  Med. 
&  Surg.  Jour.,  June  3,  1909. 


2.  ZWEIFEL.    Muench.  Med.  Woch.,  Nov.  19, 

1907. 

3.  CONVELAIRE.    Ann.  de  Oyn.  et  d'Obstet., 

Aug.,  1910. 

4.  FUTH.     Zentr.  f.  Gynak.,  1907.  12. 

5.  WARREN.     Lancet,   Feb.   3,   1906. 

6.  HAITCH.     Mon.    f.    Geb.    u.    Gynak.,    1910, 

xxxi,    5. 

7.  BONNAIRE.    Presse  Med.,  1909,  xvii,   66. 

8.  MULLER,  L.     Placenta  Praevia,  Stuttgart, 

1877. 

9.  HANNES.     Zeit.  f.  Gynak.,  1909,  3. 

10.  THIES.     Mon.    f.    Gel),    u.    Gynak.,    1909, 

xxix. 

11.  MAISON.     Zentr.  f.  Gynak.,  1910,  18. 

12.  HOLMES.    Jour.   Am,er.  Med.  Assn.,   May 

20,   1905. 

13.  JEWETT.    Amer.  Jour.  Obstet.,  June,  1909. 

14.  SIGWART.     Zentr.  f.  Gyn.,  1910,  28. 

15.  HAMMER.    Munch.  Med.   Woch.,  1,   35. 

16.  FOGES    AND    HOFSTATTER.     Zentr.    f. 

Gynak.,  1910,  46. 


CHAPTER  XVII. 

OVARIAN    PREGNANCY,    WITH    RE- 
PORT  OF  A  CASE. 

Introduction. — The  occurrence  of  ovarian 
pregnancy  was  first  proven  by  Catherine 
von  Tussenbroek  who  accidently  discovered 
a  case  while  making  pathological  examina- 
tions. She  made  her  examination  and  re- 
port of  a  specimen  handed  her  by  Kouwer. 
This  was  the  first  complete  demonstration 
of  ovarian  pregnancy  in  1899.  Since  that 
time  a  number  of  cases  have  been  reported 
and  all  that  are  well  examined  and  un- 
doubted are  collected  in  a  table  in  this 
paper.  The  first  nineteen  cases  were  col- 
lected in  Norris'  table  in  1909,  and  nine 
cases  have  been  added  to  that  table  includ- 
ing the  one  here  reported.  An  example 
of  the  fact  that  if  an  operator  is  on  the 
watch  for  this  condition  it  is  more  likely 
to  be  found  is  that  of  28  cases,  two  each 
are  reported  by  Webster,  Norris  and  Mis- 
colitsh. 

Diagnosis. — The  requirements  of  an  un- 
doubted ovarian  pregnancy  are  that  ( i )  the 
tube  on  the  affected  side  be  intact,  (2)  the 
fetal  sac  occupy  the  position  of  the  ovary, 

Page  Ninety-ttoo 


(3)  it  must  be  connected  to  the  uterus  by 
the  utero-ovarian  Hgament,  (4)  definite 
ovarian  tissue  must  be  found  in  the  sac  wall 
and  at  different  places  in  the  sac  wall. 

These  conditions  are  required  to  distin- 
guish ovarian  pregnancy  from  advanced 
tubo-oyarian  or  abdominal  pregnancy  where 
the  ovarian  tissue  is  plastered  and  flattened 
over  the  sac  wall  and  so  incorporated  in  the 
sac  wall  as  to  be  impossible  to  distinguish 
whether  the  pregnancy  is  ovarian  or  not. 

It  is  very  difficult  to  say  whether  certain 
advanced  ectopic  pregnancies  are  tubal  or 
ovarian  in  their  origin,  and  it  is  almost  im  ■ 
possible  to  prove  their  original  site.  For 
this  reason,  in  this  series  so  collected,  all 
advanced  and  dubious  cases  must  be  ex- 
cluded. 

For  an  exact  diagnosis  microscopic  ex- 
amination must  show  evidence  of  preg- 
nancy within  the  ovary,  i.  e.,  chorionic  villi 
must  be  found.  The  presence  of  decidual 
cells  alone  is  not  sufficient  evidence  of 
ovarian  pregnancy;  for  decidual  cells  may 
be  present  in  various  places,  such  as  the 
broad  ligament  over  peritoneal  surface  in 
ectopic  pregnancy.  Also,  it  may  be  pos- 
sible that  the  mere  presence  of  decidual 
cells  in  the  tube  is  not  evidence  that  gesta- 
tion has  occurred  there  and  not  in  the 
ovary,  as  it  is  possible  that  such  cells  may 
exist  in  the  tube  during  an  ovarian  preg- 
nancy. Decidual  cells  may  sometimes  be 
found  in  the  uninvolved  tube  when  a  tubal 
pregnancy  is  in  the  opposite  side,  and  again 
as  may  be  seen  from  the  discussion  of  bilat- 
eral tubal  pregnancy,  decidual  cells  some- 
times exist  in  a  tube  containing  blood  when 
no  other  signs  of  tubal  pregnancy  exist. 
So  that  decidual  cells  in  the  tube  are  no 
evidence  for  or  against  the  presence  of  an 
ovarian  gestation. 

Page  Ninety-three 


The  occurrence  of  hemorrhage  from  the 
ovary  sometimes  occurs  without  ovarian 
pregnancy  and  from  ovarian  hematoma. 
Hedley^  has  reported  18  such  cases  with 
free  peritoneal  blood,  and  has  described  the 
course  and  pathology  of  the  condition. 
Savage-  has  divided  hematomata  of  the 
ovary  into  two  types :  ( i )  hematoma  of  the 
Graffian  follicle,  (2)  hematoma  of  the 
corpus  luteum.  In  the  first  type,  he  found 
the  wall  of  the  hematoma  was  lined  by  a 
single  layer  of  epithelium  which  he  re- 
garded as  a  membrana  granulosa,  lying  on 
a  basement  membrane  and  external  to  these 
were  the  two  layers  of  tissue  which  ap- 
peared to  correspond  to  the  theca  interna 
and  theca  externa.  The  cells  of  the  inner 
layer  showed  early  lutein  cell  formation 
and  there  were  ill-developed  Graffian  fol- 
licles near  the  cavity  of  the  hematoma  and 
some  opening  into  it. 

The  second  type — ^hematoma  of  the 
corpus  luteum — had  an  outer  cell  of  ovarian 
tissue  which  was  for  the  most  part  con- 
gested; the  inner  part  of  the  wall  showed 
newly  formed  fibrous  tissue,  poor  in  cells, 
and  near  to  the  lining  in  between  the  long- 
itudinal strands  of  this  tissue,  there  were 
blood  extravasations,  many  round  cells  and 
many  large  rounded  or  cuboidal  cells  con- 
taining yellow  coarse  granules.  The  nuclei 
of  these  cells  were  relatively  small  and,  in 
many  instances,  seemed  to  be  crowded 
towards  the  periphery  of  the  cell.  The 
cause  of  these  hematomata  is  supposed  to 
be  abnormal  congestion  of  the  ovary  with 
hemorrhage  into  immature  follicles. 

It  has  been  suggested  that  it  might  be 
possible  that  ovarian  pregnancy  be  a  cause 
of  some  of  these  hematomas.     This  seemed 


*  Hedley. 

==  Smallwood    Savage.    Brit.    Oyn.   Jour.,   xxi, 
285. 


possible  because  several  cases,  as  von  Tus- 
senbroek's  and  Kelly  and  Mcllroy's,  were 
discovered  accidentally  in  the  routine  ex- 
amination of  surgical  specimens.  How- 
ever, search  does  not  bear  this  out.  Still 
the  similarity  of  the  picture  at  operation 
between  ovarian  hematoma  and  ovarian 
pregnancy,  both  causing  hemorrhage,  is 
very  striking  and  requires  careful  examina- 
tion to  distinguish  one  from  the  other. 

The  clinical  course  of  ovarian  pregnancy 
has  nothing  to  distinguish  it  from  ectopic 
pregnancy  generally.  The  rupture  occurs 
in  the  same  way;  the  shock  and  collapse 
may  be  as  extreme  and  the  hemorrhage  is 
sometimes  great.  The  condition  is  chiefly 
of  interest  because  of  its  rarity. 

Clinical  Report — Mrs.  L.,  age  36,  para  I. 
Small  woman.  Good  previous  history. 
Severe  cystitis  5  years  ago.  Operated  upon 
by  Dr.  Ellice  McDonald  for  retroversion  b}- 
internal  round  ligament  operation.  Opera- 
tion was  done  four  years  ago.  When  seen 
complained  of  pain  on  left  side.  Menstrua- 
tion has  been  absent  for  37  days.  Thought 
she  was  pregnant.  Tenderness  on  right  side 
on  abdominal  palpation.  Tenderness  on 
movement.  Uterus  contracted  and  firm, 
not  enlarged.  Cervix  slightly  patulous. 
No  softening  of  cervix,  no  contractions  of 
the  uterus.  Hegar's  and  McDonald's  signs 
not  found.  Light  colored,  bad  smelling  dis- 
charge from  cervix.  Doughy  mass  was 
felt  posteriorly  and  to  the  left  slightly  dis- 
placing the  uterus.  Diagnosis  was  made  of 
ectopic  pregnancy  which  was  concurred  in 
by  Dr.  H.  M.  Painter,  who  was  called  in 
consultation.  Immediate  operation.  Dr. 
Painter  assisting.  Free  bloody  fluid  was 
found  in  the  pelvis  and  on  the  left  side  in  the 
region  of  the  ovary  and  attached  to  the 
ovarian  ligament  was  found  a  thin  walled 
cyst  about  the  size  of  a  large  walnut  from 
the  interior  of  which  was  attached  a  stringy 
piece  of  dark  reddish  membrane  (decidual 
remnant).  This  was  fixed  to  the  inner 
lining  of  the  cyst  way.  This  membrane 
has  evidently  before  the  rupture  covered 
the  interior  of  the  cavity  within  the  ovary. 
The  capsule  was  very  thin  in  parts,  varying 


in    thickness.     One    part    was    densely    in- 
filtrated with  blood. 

The  tube  was  apparently  normal  and  was 
removed  with  the  ovarian  mass.  *There  was 
no  trace  of  a  fetus.  Microscopic  examina- 
tion showed  that  the  walls  of  the  cyst  were 
formed  of  ovarian  tissue  with  several 
corpora  lutea  at  various  stages.  Numerous 
Grafiian  follicles  were  found.  Numerous 
chorionic  villi  could  be  seen,  although  in 
many  sections  obscured  by  fibrin  and  clots. 
In  the  walls  of  the  capsule  there  were  areas 
of  hemorrhages  in  the  stroma.  There  was 
a  moderate  round-celled  infiltration  in 
places.  Pigmentation  was  present  almost 
in  all  sections  of  the  ovarian  stroma.  Here 
and  there  were  groups  of  large  pigmented 
cells  with  large  nuclei.  Here  and  there 
were  budlike  masses  with  densely  staining 
multiform  nuclei  or  protoplasmic  cells  with 
nuclei.  The  tube  was  normal.  Diagnosis 
— ovarian  pregnancy. 

CASES    REPORTED    IN    LITERATURE. 

ANNING  &  LITTLEWOOD.— Trans.  Obst.  Soc, 

London,  1901.     xliii,  14. 
WEBSTER. — Trans.     Amer.     Gyn.     Soc.     1904. 

xxix,   65. 
HEWETSON  &  LLOYD.— BH*.  Med.  Jour.  1906. 

Sept.  8. 
VAN  TUSSENBROEK.— Awn.  de  Gyn.  et  O'bst. 

1899.     Dec. 
DE  LEON  &  HALLMAN.— 2?ev.  de  Gyn.     1902. 

June. 
FREUND  &  THOME. — Virchow's  Arch.     1906. 

Jan. 
KELLY  &  McILROY.— Jowr.  O'bst.  &  Gyn.  Brit. 

Emp.     1906.     June. 
THOMPSON.— Trans.     Am.     Gyn.     Soc.     1902, 

xxvii. 
WEBSTER. — Trans.    Amer.    Gyn.    Soc.       1907, 

xxxii. 
BOESBEECH. — Monat   f.    Gel),   u.    Gyn.      1904, 

XX,    613. 
JACOBSON. — Contribution    to    the    Science    of 

Med.  &  Sur.     N.  Y.  Post-Grad.  School  and 

Hospital.     1908,  24. 
MISCHOLITSCH.— Zewf.  f.  Geh.  u.  Gyn.     1903, 

49,  500. 
NORRIS     &     MITCHELL.— Surg.     Gyn.     Obst. 

1908,  May. 
KERR,  J.   M.   MUNRO.— Proc.   Roy.   Soc.   Med. 

1908.  I.  9. 
GOTTSCHALK.— Zent   f.   Gyn.     1886,  x,   727. 
BANDEL.— Betir.   z.  Klin.   Chir.      1902,   xxxvi, 

657. 
¥RANZ.— Hegar's  Beitrdge.      1902,   vi,   70. 
SCHICKELE.— Beit  z.   Geh.  u  Gyn.      1906,  xi, 

307. 
RUBIN. — Amer.  Jour.  Obstet.     1911,  May. 
-LBA.— Jour.    Ohst.    &    Gyn.    for   B.   E.       1910. 

Sept. 

Page  Ninety-four 


TUEEDY.— r/Ottr.  01)st.  d  Gyn.  for  B.  E.     1910, 
Feb.  oArv    T- 

Mcdonald,  n.  ^.—Jour.  a.  m.  a.    i909,  m, 

1253.  ^    ^ 

BARROWS. — Amer.  Jour.  Ohstet.     1910,  Dec. 
YOUNG  &  RHEA.— Boston  Med.  &  Sxirg.  Jour. 

1911,  Feb.  23. 


CHAPTER  XVIII. 
THE  UNSOLVED  PROBLEM. 

The  duty  of  a  physician  is  three  fold; 
first  to  cure  the  sick,  second  to  teach  others 
to  cure  the  sick,  and  third  to  study  disease 
and  find  remedies  to  cure  the  sick.  Each 
of  these  is  necessary  to  the  complete  physi- 
cian, and  without  them,  he  fails  in  some 
part.  To  cure  the  sick  is  admirable,  to 
teach,  "delightful  task  to  rear  the  tender 
thought,"  is  laudable;  but  to  discover  the 
processes  of  disease  and  its  cure,  ap- 
proaches the  highest  kind  of  duty. 

To  heal  the  sick  is  the  function  of  the 
physician  and  aids  those  whom  he  touches ; 
but  pupils,  taught  to  heal,  go  forth  like  the 
apostles  to  carry  the  word  to  others.  One 
man's  knowledge  imparted  to  others  is  mul- 
tiplied in  proportion  to  the  numbers  he 
teaches  and  the  power  he  has  of  imparting 
his  experience.  Those  he  teaches  depend, 
however,  more  upon  the  character  of  the 
man  and  his  influence  over  them  as  an  up- 
lifting stimulus  which  spurs  them  to  greater 
efforts  and  keeps  their  ideals  exalted.  The 
spoken  word  is  forgotten,  but  the  memory 
of  the  man  remains.  So,  while  it  is  im- 
portant to  teach  medicine,  it  is  more  impor- 
tant to  teach  the  methods  of  the  study  of 
medicine.  A  student's  study  does  not  cease, 
but  should  extend  throughout  his  lifetime. 
Habits  of  accuracy  of  thought  and  methods 
of  observation  are  the  foundation  upon 
which  the  physician  may  rear  the  super- 
structure of  his  life. 


If  he  have  not  these,  he  will  be  spurious 
and  not  true  coin,  "a  kind  of  semi-Solomon, 
half  knowing  everything  from  the  cedar  to 
the  hyssop."     And  this  alone  is  not  suffi- 
cient; he  must  in  addition  be  taught  what 
has    been    known    and    where   to    find    it. 
"Knowledge  is  of  two  kinds.     We  know  a 
subject  ourselves  or  we  know  where  we  can 
find  information  about  it."     No  man  can 
hope  to  achieve  a  working  knowledge  of 
medicine  in  four  years ;  the  span  of  life  is 
all  too  short  to  grasp  more  than  a  moiety  of 
it.     The  task  is  so  great  that  we  must  waste 
no  time  on  useless  efforts  and  vain  imagin- 
ings.      "Naught    but    firmness    gains    the 
prize,  naught  but  fullness  makes  us  wise, 
buried   deep,  truth   ever  lies."     We  must 
demand  that  we  be  taught  what  has  been 
done  in  the  past  and,  of  the  past,  what  is 
truth  and  what  is  speculation.     This  lack 
of  perspective  in  the  study  of  medicine  is 
a  fault  of  teaching,  often  due  to  a  desire  of 
the  teacher  to  appear  an  oracle  and  that  all 
his  words  be  taken  as  truth.     The  student 
magnifies  authority  and  bows  down  before 
reputation.     This  is  fatal  to  true  perspec- 
tive of  the  study  of  disease.     When  you 
know  a  thing,  to  hold  that  you  know  it; 
and  when  you  don't  know  a  thing,  to  allow 
that  you  do  not  know  it ;  that  is  knowledge. 
"Mark  not  who  said  this  or  that,  but  mark 
the  words  spoken,"  said  Thomas  a  Kempis. 
"I    open   the  truth,"    said   Confucius,    "to 
help  only  those  who  want  to  help  them- 
selves.    My  teaching  is  a  solid  square,  but 
I  present  only  one  corner  of  the  subject — 
I   expert  you  to  find  the  other  comers." 
This  must  be  the  teacher's  true  attitude. 

If  the  improvement  of  understanding  is 
for  two  ends ;  first,  for  our  own  increase  of 
knowledge,  secondly,  to  enable  us  to  deliver 
and  make  out  that  knowledge  to  others, 
how  much  better  is  it  that  we  should  inves- 


Page  Ninety-five 


tigate  and  study  and  discover  for  ourselves 
and  impart  our  results  to  others. 

This  is  the  supreme  function  of  the  phy- 
sician. 

If  we  can  reach  a  few  by  our  work,  a  few 
more  by  our  students,  how  many  more  can 
we  reach  by  the  printed  line  and  typed 
page,  read  by  all  the  world  of  earnest  men 
who  have  that  "natural  feeling  of  mankind, 
a  desire  for  knowledge.  Every  human 
being  whose  mind  is  not  debauched  will  be 
willing  to  give  all  that  he  has  to  get  knowl- 
edge." My  profession,  sworn  idealists 
and  practical  altruists,  is  not  worse  than  the 
average  of  mankind,  and  wishes  for  each 
addition  to  the  sum  of  medical  experience 
with  a  longing  as  that  of  Naaman  for  the 
healing  waters  of  Pharfar  and  Abana, 
rivers  of  Damascus. 

To  alleviate  human  suffering  and  prevent 
human  ills,  must  be  our  portion.  To  do 
this,  it  is  not  sufficient  to  rest  content  with 
our  field  as  we  find  it,  but  we  must  experi- 
ment and  cultivate  anew.  "I  will  not  fol- 
low where  the  path  may  lead,"  said  Strode, 
"but  I  will  go  where  is  no  path  and  I  will 
leave  a  trail." 

The  scientific  study  of  medical  problems 
is  part  of  the  work  of  every  practitioner. 
Science  is  not  confined  within  the  four 
walls  of  the  laboratory,  nor  such  a  rare  bird 
that  it  is  never  caught  by  the  clinician.  The 
great  present  day  problems  are  those  of 
practical  application  and  not  those  of  pure 
science.  Every  man  should  feel  that  his 
profession  requires  of  him  something  more 
than  its  practice  as  a  means  of  his  liveli- 
hood; he  has  a  debt  to  pay,  to  add  to  the 
sum  of  its  knowledge. 

Clinical  research  is  the  greatest  of  all 
medical  blessings.  "It  is  twice  blessed.  It 
blesseth  him  that  gives  and  him  that  takes." 
It  gives  to  the  worker  an  intimate  and  ex- 


act knowledge  of  his  subject  which  can  be 
obtained  in  no  other  way,  and  it  benefits 
untold  numbers  whose  physicians  are  read- 
ers and  learners  all  over  the  world.  Dif- 
fused. knowledge  immortalizes  itself.  It  is 
a  task  which  is  never  done  as  each  piece  of 
research  opens  to  the  scientific  imagination 
more  fields  to  work  in  and  more  problems 
to  solve.  The  reward  of  duty  is  the  power 
to  fulfill  another,  and  each  clinical  problem 
constitutes  a  pledge  of  duty  to  which  every 
physician  is  bound  to  consecrate  his  every 
faculty  to  its  fulfilment.  By  this,  we  m.ay 
best  fulfil  the  precept  of  the  Great  Physi- 
cian, "Go  ye  to  all  the  world,  to  every  peo- 
ple *  *  *." 

In  return,  the  research  worker  will  gain 
in  knowledge,  in  power,  an  unending  inter- 
est and  unfailing  occupation.  It  does  not 
require  that  vast  and  grand  discoveries 
should  be  made.  They  seldom  are  except 
by  men  who  have  served  their  apprentice- 
ship in  the  day  of  small  things,  and  so  had 
training  in  the  discipline  of  study  and  ac- 
curacy of  observation.  If  each  adds  his 
stone  to  the  arch,  what  matters  who  lays 
the  keystone.  The  plaudits  may  be  his ; 
but  he  knows  and  the  privates  in  the  army 
of  research  know  what  contributions  have 
gone  before  to  make  his  victory  possible. 
"Knowledge  is  the  hill  where  few  may 
climb ;  duty  is  the  path  where  all  may 
tread." 

All  physicians  owe  this  duty — ^to  con- 
tribute their  quota,  however  small,  to  the 
sum  of  medical  knowledge.  It  should,  how- 
ever, be  approached  in  a  true  spirit  of  unsel- 
fishness, the  spirit  of  disinterested  curiosity 
which  is  the  real  flower  of  intellectual  life. 
How  else  can  he  weigh  and  judge  the  facts 
and  observe  truly  unless  the  motive  of  self- 
interest  is  put  aside?  Intellectual  honesty 
is  the  true  test  to  separate  work  that  has 


Page  Ninety-six 


distinction  from  work  that  has  it  not. 

In  gynecology  and  obstetrics,  the  prob- 
lems which  remain  unsolved  are  many.  The 
early  gynecologists  were  the  forerunners 
in  abdominal  surgery,  and  the  names  of 
McDowell,  Emmett,  Sims,  James  Simpson 
and  Lawson  Tait  should  be  engraved  upon 
the  minds  of  all  surgeons.  However,  surgery- 
has  now  come  into  its  own  in  research,  and 
there  remain  for  the  student  of  diseases  of 
women  many  problems  which  have  to  do 
with  disordered  function  rather  than  the 
surgical  correction  of  tumors,  growths  and 
obstetrical  trauma.  Among  these  subjects 
are  sterility  and  its  causes,  the  menstruation 
and  menstrual  disorders,  the  relation  of  the 
glands  of  internal  secretion,  particularly  the 
ovary,  to  the  health  of  women,  and  many 
other  so-called  medical  subjects.  One  great 
problem  is  that  of  the  hypoplastic  woman 
with  her  many  and  varied  evidences  of  ab- 
normality. This  asthenia  congenitalis,  con- 
genital hypoplasia,  or  whatever  name  the 
symptom-complex  may  be  given,  is  more  or 
less  a  biological  problem,  inasmuch  as  it 
has  to  do  with  the  relation  of  an  abnormal 
or  aberrant  type  of  woman  as  an  animal  to 
the  normal  or  common. 

In  obstetrics,  the  field  is  still  virgin. 
Bacteriology  has  had  its  miracles  and  sur- 
gery its  victories,  but  obstetrics  leads  im- 
potent and  snail  paced  beggary.  The  four 
great  complications  in  pregnancy,  con- 
tracted pelvis,  placenta  previa,  toxemia  of 
pregnancy  and  eclampsia,  and  puerperal  in- 
fection are  still  unsolved,  and  their  treat- 
ment still  disputed  and  obscure. 

Of  these  problems,  the  greatest  is  puer- 
peral infection.  Puerperal  infection  is  no  less 
prevalent  in  private  practice  than  it  v/as  be- 
fore the  days  of  antiseptic  methods.  In  hos- 
pital practice,  the  mortality  is  very  much  re- 
duced, yet  there  is  record  of  hospital  epi- 


demics   even    in   these   latter    years.       To 
estimate  the  prevalence  of  this  condition  is 
difficult     because     in     mortality     statistic? 
women  dying  from  puerperal  infection  are 
frequently  recorded  under  the  disease  of 
the  organ  which  the  infection  attacks ;  for 
example,    as    peritonitis,    from    salpingitis, 
septic  pneumonia,  and  other  terminal  ex- 
pressions   of    infection.      Puerperal   infec- 
tion is  considered  by  the  laity  to  be  due  to 
lack  of  care  upon  the  part  of  the  doctor, 
and  for  this  reason,  physicians  dislike  to 
register  a  possible  criticism  against  them- 
selves.    So  the  mortality  statistics   in   re- 
gard to  death  from  puerperal  infection  are 
very  inaccurate,  and  much  under  the  actual 
rate  of  occurrence.  Prof.  Leopold,  in  1907, 
stated  that   in   Prussia  4,339  and   in  the 
German  Empire  6,000  deaths  occurred  from 
puerperal   infection   in  the  previous   year. 
Boche  in  an   investigation  extending  over 
sixty  years,  and  involving  363,624  deaths, 
stated  that  in   Prussia  6,060  women  died 
each   year    from  puerperal   infection,    and 
that,  in  1907,  there  were  6,000  deaths,  show- 
ing no  decrease  in  the  mortality.     There 
has  been  no  improvement  in  the  maternal 
mortality,  except  in  hospital  clinics  for  the 
last   twenty   years.     Cullingworth    from   a 
study  of  the  Registrar-General's  statistics 
for  1897  said  that  there  had  been  no  de- 
crease between  the  years  of  1843  and  1897 ; 
he  said  "Puerperal  fever  continues  to  pre- 
vail as  though  Pasteur  and  Lister  had  never 
lived.     There  is  needed  a  strong  voice  to 
rouse  us  from  our  lethargy  and  to  plead 
with  desperate  earnestness  for  the  lives  that 
are  still  being  unnecessarily  sacrificed." 

In  the  mortality  statistics  of  the  U.  S. 
census  of  1910,  3,892  deaths  from  puerperal 
infection  are  recorded  in  the  registration 
area,  which  comprises  three-fifths  of  the 
total  population  of  the  United  States.     On 


Page  Ninety-seven 


this  basis,  there  would  have  been  from  the 
whole  population  5,485  deaths  from  puer- 
peral infection  registered  each  year  from 
the  whole  of  the  United  States.  This  num- 
ber of  deaths  is  probably  much  under- 
estimated on  account  of  the  difficulty  of 
obtaining  accurate  registration  on  death 
certificates.  It  is  unreasonable  to  suppose 
that  with  a  much  greater  population,  and 
in  the  care  of  physicians  with  less  exact 
training  that  there  should  be  a  smaller  mor- 
tality from  puerperal  infection  than  there 
is  in  Germany.  It  is  probable  that  the 
mortality  from  puerperal  infection  through- 
out the  United  States  is  not  less  than 
12,000  women  annually.  This  is  based  on 
the  census  statistics,  and  upon  the  probable 
ratio  of  deaths  from  puerperal  infection  to 
the  total  number  of  births.  In  the  City  of 
New  York  for  the  year  1910  the  total  num- 
ber of  births  was  129,080,  and  the  deaths 
registered  as  caused  by  puerperal  infection 
was  225,  a  mortality  of  .02  per  cent.  This 
mortality  is  about  eighteen  times  less  than 
the  mortality  of  an  obstetrical  hospital  in 
the  same  city  and  less  than  the  best  clinic 
report  that  could  be  found  anywhere  in  the 
world.  So  the  registration  is  obviously 
very  much  under-estimated  and  hopelessly 
unreliable.  It  is  probable,  basing  the  esti- 
mate upon  the  reports  of  other  cities  and 
upon  the  proportion  of  puerperal  infection 
to  the  total  number  of  births  in  other  places 
and  in  clinics  that  more  than  700  women 
die  annually  in  New  York  from  puerperal 
infection.  An  example  of  the  inaccuracy 
of  the  registration  is  that  Berlin,  a  clean 
city. with  well  trained  physicians  and  exact 
registration  returns,  has  a  mortality  rate 
per  100,000  population  of  35.1  for  puer- 
peral infection.  In  New  York,  on  the  con- 
trary, the  mortality  rate  for  100,000  popu- 


lation is  7.8.  This  shows  the  inconsisten- 
cies of  registration. 

Thus  it  may  be  seen  that  puerperal  in- 
fection in  spite  of  the  advances^in  technic 
has  not  yet  disappeared,  and  is  still  worthy 
of  study. 

The  total  deaths  from  cancer  for  the  year 
1910  amounted  to  41,000  and  the  average 
age  at  death  was  59.2  years;  amongst  the 
cases  of  puerperal  infection  the  average  age 
at  death  was  27  years.  Puerperal  infection 
thus  takes  its  dreadful  toll  amongst  women 
in  their  early  married  life  when  the  great 
part  of  their  usefulness  in  the  family  and  in 
the  world  is  still  before  them.  They  die 
to  leave  small  children  and  sorrowing  hus- 
bands. The  economic  loss  to  the  United 
States  of  such  young  and  useful  beings  is 
in  itself  no  small  one.  In  cancer,  on  the 
other  hand,  death  occurs  amongst  those 
who  have  exceeded  the  probable  duration 
of  life  by  twenty  years,  and  who  are  getting 
toward  the  end  of  their  usefulness  in  the 
world.  The  prolonged  suffering  and  the 
fact  that  the  person  afflicted  is  usually  of 
an  age  when  the  patient  has  children,  a 
position  in  the  world,  and  a  hold  upon  the 
affections  of  those  around  him,  make  cancer 
a  disease  for  which  it  is  easy  to  obtain  re- 
search workers  and  money  to  support  them. 
At  the  present  time  the  public  eye  is 
occupied  by  the  neo-alchemists  with  their 
philosopher's  stone.  The  problem  of 
puerperal  infection  is  different.  Here 
women  die  quickly,  silently  slip  out  of  the 
world,  and  their  memory  is  marked  only 
upon  the  hearts  of  their  young  children  and 
bereaved  relatives.  Yet  a  woman  dead 
from  puerperal  infection  is  just  as  dead  as 
one  from  cancer,  but  I  have  not  yet  seen 
any  laboratory  erected  for  the  study  of 
puerperal  infection,  or  any  money  left  as 


Page  Ninety-eight 


a  foundation  for  its  investigation. 

The  possibility  of  solving  the  problem 
of  puerperal  infection  is  infinitely  greater 
than  that  of  cancer.  The  causes  of  puer- 
peral infection  are  known,  and  prevention 
is  but  a  problem  of  the  application  of 
proper  methods  and  a  more  thorough 
knowledge  of  the  processes  of  the  infection. 
Amongst  obstetricians  at  the  present  time 
the  most  popular  treatment  of  puerperal  in- 
fection is  a  laisser  faire,  do-nothing  policy. 
They  claim  that  more  women  with  puer- 
peral infection  get  well  if  they  are  left 
alone  than  with  any  known  method  of  treat- 
ment. This  does  not  mean  that  their 
opinion  is  correct,  but  that  most  known 
methods  of  treatment  are  ineffectual  or 
harmful.  There  is  no  more  reason  why 
the  processes  of  infection  through  the 
uterus  should  go  untreated  than  that  infec- 
tion elsewhere  in  the  body  should  be  left 
to  itself. 

The  problem  of  puerperal  infection  is 
however,  essentially  one  of  prevention.  The 
three  avenues  from  which  infection  may 
occur  consist,  first,  of  the  obstetrician  and 
his  instruments,  second,  of  the  vulva  and 
outward  genitalia,  and  third,  of  the  vagina. 
If  all  these  can  be  made  to  harbor  no  infec- 
tious organisms,  the  probability  of  puer- 
peral infection  would  be  very  slight. 

The  surgeon's  hands  and  the  instruments 
may  be  sterilized  so  that  there  is  little 
danger  of  infection  there.  The  vagina,  as 
a  rule,  before  labor,  contains  few,  if  any, 
pathogenic  organisms,  but  the  vulva  and 
outward  genitalia  almost  constantly  harbor 
pathogenic  organisms  of  varying  degrees  of 
virulence.  In  the  puerperium,  streptococci, 
as  well  as  other  bacteria  may  pass  up  from 
the  vulva  into  the  vagina,  and  on  the  third 
day  of  the  puerperium  the  vaginal  lochia 
of  about  half  of  all  the  cases  of  childbirth 


contains  pathogenic  organisms.  It  is  ob- 
vious, therefore,  that  the  elimination  of 
puerperal  infection  must  depend  to  a  large 
extent  upon  antiseptic  methods  and  pre- 
ventive measures. 

In  the  consideration  of  what  antiseptic 
measures  may  be  taken  it  is  possible  that 
return  may  be  made  to  the  antipartum 
douche.  The  vaginal  secretions  have  always 
been  said  to  have  some  bactericidal  power 
because,  if  bacteria  are  inserted  into  the 
vagina,  they  usually  cannot  be  recovered 
after  some  days.  It  is  probable,  however, 
that  the  bactericidal  properties  of  the 
vaginal  secretions  are  small  or  almost  nil, 
and  that  the  disappearance  of  the  bacteria 
is  due  to  the  drainage  and  to  the  fact  that, 
in  the  absence  of  trauma,  bacteria  will  dis- 
appear from  almost  any  epithelial  surface. 
This  is  well  shown  by  the  introduction  of 
bacterial  cultures  into  the  bladder,  which 
cause  no  danger  unless  traumatic  conditions 
are  present. 

Heretofore,  experiments  in  regard  to  an- 
tipartum douches  have  usually  been  done 
with  bichloride  of  mercury  and  formalin. 
Formalin  is  a  very  weak  bactericide  hav- 
ing about  one-third  the  strength  of  phenol, 
and  is  inert  in  the  presence  of  albuminoid 
substances,  such  as  mucous  membrane  and 
vaginal  secretions.  Bichloride  of  mercury 
is  also  rendered  inert,  inefficient  and  use- 
less in  the  presence  of  organic  matter,  as 
soap,  pus,  mucous  membrane  and  vaginal 
secretions.  As  a  result,  neither  of  these 
so-called  germicides  have  any  efifect  upon 
the  vaginal  flora,  and  only  act  as  irritants 
to  the  mucous  membrane.  Bichloride  of 
mercury,  in  addition,  on  account  of  poison- 
ous action,  is  a  dangerous  germicide  to  use 
at  labor  when  the  huge  raw  surface  of  the 
uterus  is  capable  of  absorption,  and  num- 
bers of  deaths  have  been  reported  after  its 


Page  Ninety-nine 


use.  The  ideal  obstetrical  germicide  should 
be  unirritating,  not  poisonous,  and  efficient 
as  a  germicide  in  the  presence  of  organic 
matter. 

Burckhardt  and  Kolb  (Zeit.  f.  Geburt. 
u.  Gyn.  1911-LXVIII-l)  made  a  study  of 
seven  hundred  women,  half  of  whom  re- 
ceived douches.  Excluding  all  pathological 
labors,  it  was  found  that,  amongst  the 
douched  patients,  there  was  a  morbidity  of 
6.5%,  and,  amongst  the  non-douched  pa- 
tients, there  was  a  morbidity  of  8.6%.  They 
used  a  solution  of  chlor-m-kresol,  one  to 
four  hundred,  with  a  bactericidal  power  sev- 
eral times  stronger  than  phenol,  and  possess- 
ing none  of  the  destructive  powers  which  bi- 
chloride of  mercury  exerts  upon  the  epithe- 
lium. They  conclude  that  the  post-partum 
douche  retarded  bacterial  growth  for 
several  days.  The  patient  received  no 
germicidal  treatment  after  the  first  day.  It 
is  possible  that,  when  the  vulvar  parts  are 
washed  each  day  with  a  similar  non-irri- 
tating germicidal  solution,  that  the  organ- 
isms might  be  absent  for  a  longer  period. 
This  study  is  of  great  interest  from  the 
point  of  view  of  the  preventive  treatment 
for  puerperal  infection. 

There  are  at  present  many  other  new 
germicides,  which  are  efficient  in  the  vagina 
and  considerably  more  germicidal  than 
chlor-meta-kresol.  The  investigation  of 
this  aspect  of  the  problem  in  a  large  clinic 
would  be  of  great  interest. 

It  is  important  that  no  dangerously 
poisonous  germicide  should  be  used  in  the 
preventive  or  other  treatment  of  puerperal 
infection. 

The  preparations  of  cresylic  acid  are 
popular  obstetrical  germicides.  Witthaus 
(Wittaus  and  Becker,  Medical  Jurispru- 
dence, 1911,  Vol.  4,  p.  1187)  has  collected 
133   cases  of  poisoning   from  one  of  the 


most  popular  of  these  preparations,  of 
which  11  cases  followed  irrigation  of  the 
uterus.  Other  cresylic  acid  prefrarations, 
including  liquor  cresolis  compositus  of  the 
U.  S.  P.  have  similar  dangers.  The  essen- 
tial, after  efficiency  in  an  obstetrical  ger- 
micide, should  be  its  non-poisonous  char- 
acter as  it  must  often  be  introduced  into 
the  vagina  after  labor  or  in  the  puerperium 
when  there  is  great  possiblity  of  absorp- 
tion from  the  large  raw  surface  of  the 
uterus.  The  development  of  an  unirritat- 
ing non-poisonous  germicide,  efficient  in  the 
presence  of  organic  matter,  would  be  of 
itself  a  great  contribution  to  the  prevention 
of  puerperal  infection. 

The  processes  of  infection  in  puerperal 
fever  have  not  received  intelligent  study. 
By  this  is  not  meant  that  time  and  labor 
have  not  been  expended,  but  that  puerperal 
infection  has  been  thought  to  be  a  disease 
apart  and  not  to  follow  the  ordinary  course 
of  infection  as  does  lymphangitis  of  the 
arm,  erysipelas  or  peritonitis.  It  is  true 
that  the  infection  is  much  modified  by  the 
softened  and  vascular  pelvic  organs  under- 
going as  they  do  a  sort  of  degeneration  of 
involution.  In  addition,  the  large  lymphatic 
and  vascular  supply  of  the  pelvis  with  its 
adjacent  large  vessels  and  the  lessened  re- 
sistance of  the  pregnant  woman  do  seriously 
alter  the  course  of  the  infection.  Still  the 
processes  of  inflammation  and  infection  are 
fundamentally  alike  and  a  great  deal  of  our 
lack  of  knowledge  is  due  to  the  fact  that 
autopsies  are  not  often  obtained  and,  when 
obtained,  the  pathological  findings  are 
usually  not  properly  studied.  This  is  be- 
cause pathologists  are  seldom  familiar  with 
conditions  of  pregnancy  as  they  come  but 
rarely  in  their  routine  autopsy  work  and, 
more's  the  pity,  there  are  few  pathologist- 
obstetricians. 


Page  One  Hundred 


The  bacteriology  in  spite  of  the  large 
amount  of  study  which  has  been  given  it, 
is  not  yet  settled.  The  role  of  the  gonococ- 
cus  in  puerperal  infection  has  not  been  de- 
termined. Stone,  Mayer,  Gurd  and  myself 
have  shown  with  pitifully  incomplete 
studies  that  a  very  large  number  of  cases 
of  puerperal  fever  are  due  to  this  organism. 
I  have  reported  in  this  series  a  case  of  death 
with  pure  culture  of  gonococcus,  and  Gurd 
has  reported  a  series  of  bacteriologically 
studied  cases  where  the  type  of  infection 
from  the  gonococcus  was  severe  and  the 
fever  high.  One  case  died.  The  lack  of 
success  of  previous  investigators  in  the 
cultivation  of  this  organism  has  been  due, 
as  is  well  shown  by  Gurd  (Amer.  Joiirn. 
Med.  Sci.,  1908,  Dec.  9,  and  Jour.  Med.  Re- 
search, 1908,  XVIII,  291)  to  improper 
media  and  to  the  fact  that  the  cultures  were 
taken  by  aspiration  through  a  tube.  This 
gave  feeble  or  dead  organisms  and,  when 
the  culture  was  taken  by  swabbing  the 
surface  of  the  endometrium,  discovery  and 
growth  of  the  organism  was  more  frequent. 
The  difficulty  of  cultivation  of  this  organ- 
ism is  well  known  and  Gurd  has  obtained 
good  results  with  blood  agar  media  of  a 
titer  of  .5  phenolphthalein   (hot  titration). 

Media  for  the  cultivation  of  the  gono- 
coccus as  well  as  for  anerobic  and  hemolytic 
organisms  should  be  in  the  armamentarium 
of  every  investigator  into  the  bacteriology 
of  puerperal  infection.  It  is  possible  that 
the  gonococcus  may  be  found  to  be  one  of 
the  fertile  causes  of  puerperal  infection, 
and  that  the  difficulty  of  cultivation  and 
recognition  will  explain  the  fact  that  puer- 
peral fever  is  still  so  prevalent  in  spite  of 
our  present  methods.  Gonococcus  puer- 
peral infection  after  recovery  from  the 
initial  attack  remains  as  a  chronic  pelvic 
inflammation,   in  this  way   differing   from 


most  other  infecting  organisms.  The  late 
crippling  effect  of  gonococcus  puerperal  in- 
fection renders  it  a  more  serious  condition 
than  is  commonly  recognized  and  make  its 
prevention  a  necessity. 

The  knowledge  of  the  prognosis  of  puer- 
peral infection  is  almost  unknown.  All  we 
know  is  that  puerperal  infection  is  a  self- 
limited  disease,  like  erysipelas,  and  tends  to 
a  spontaneous  cure.  The  influence  of  ex- 
haustion has  been  shown  by  Williams  {Bos. 
Med.  Surg.  Jour.,  Sept.  22,  1910)  and  Wirz 
(Hegars  Beitrage  z.  Geb.  u.  Gyn.,  1909) 
to  be  a  great  factor.  Puerperal  morbidity, 
with  the  exception  of  mastitis,  is  increased 
in  direct  proportion  to  the  duration  of  labor 
and  the  morbidity  after  low  forceps  was 
less  than  that  after  spontaneous  labor,  pre- 
sumably because  labor  was  shortened  and 
exhaustion  lessened. 

A  persistently  high  pulse  rate,  even  with 
relatively  slight  fever,  is  serious  ground 
for  alarm  especially  when  the  temperature 
subsides  as  the  pulse  rate  increases.  Jaschke 
(Zeit.  f.  Geb.  u.  Gyn.,  1910,  LXVI,  2)  states 
that  the  paralysis  of  the  splanchnic  vessels 
is  the  index  of  the  severity  of  the  disease, 
while  it  is  the  main  source  of  danger.  The 
blood  pressure  and  the  second  aortic  sound 
show  the  condition  of  the  vessels  and  the 
possible  compensatory  power  of  the  heart. 
In  cases  where  the  blood  pressure  does  not 
decline  or  the  decline  is  followed  by  return 
to  normal,  the  prognosis  is  good.  A  dis- 
cordance between  the  pulse  rate  and  tem- 
perature is  a  serious  indication. 

Delirium  is  a  rare  symptom  and  one  of 
utmost  gravity.  Instead  of  being  anxious 
and  disturbed,  the  patient  may  present  an 
exaggerated  feeling  of  well-being  and  ex- 
press a  desire  to  undertake  her  usual  occu- 
pations. In  56  cases  with  delirium,  39 
ended  fatally.     Its  occurrence  between  the 


Page  One  Hundred  One 


third  and  eighth  day  of  such  illness  is  a 
prognostic  symptom  of  the  utmost  gravity. 
The  prognosis  as  well  as  all  other  parts  of 
the  problem  offer  a  great  field  for  investiga- 
tion. 

The  serum  or  vaccine  treatment  of  puer- 
peral infection  offers  but  little  hope  of  cure. 
It  is  to  be  remembered,  in  streptococcus  in- 
fection, the  small  amount  of  toxin  devel- 
oped and  the  absence  of  bactericidal  prop- 
erties in  the  blood  makes  it  probable  that 
the  relief  from  this  form  of  infection  comes 
through  leukocytosis  and  not  through  the 
formation  of  antibodies.  In  animals 
treated  with  streptococci,  phagocytosis  is 
an  important  factor  in  the  production  of 
immunity  and  the  serum  exhibits  neither 
bactericidal  activity  with  respect  to  micro- 
organisms nor  antitoxic  effect  with  respect 
to  the  action  of  filtrates  of  cultures. 

From  the  evidence,  both  clinical  and  ex- 
perimental, it  may  be  concluded  that  anti- 
streptococcus  sera  and  vaccines  as  at  pres- 
ent prepared  have  but  slight  protective 
and  curative  value.  It  is  to  be  remembered 
that  puerperal  infection  is  a  self-limited  dis- 
ease which  tends  to  a  spontaneous  cure, 
like  erysipelas,  and  the  limitation  of  the 
infection  is  often  ascribed  to  the  serum  or 
vaccine  when  it  would  have  occurred  in  any 
case.  Erdman  (/.  A.  M.  A.,  1913,  Dec.  6) 
has  shown  in  the  analysis  of  800  cases  of 
erysipelas  that  this  form  of  streptococcus 
infection  was  not  benefitted,  but  the  recov- 
ery delayed  and  the  morbidity  increased  by 
sera,  vaccines  and  filtrates  of  cultures. 

The  use  of  vaccines  in  puerperal  fever 
has  little  or  no  scientific  foundation.  In 
the  words  of  Theobald  Smith  {J.  A.M.  A., 
1913,  May  24)  "The  medical  profession 
should  see  to  it  that  vaccine  therapy  does 
not  degenerate  into  inconsiderate  and  reck- 
less experiments  upon  human  beings,  that 


it  does  not  create  false  hopes  in  hosts  of  pa- 
tients and  that  it  does  not  originate  and 
end  in  commercialism  and  the  desire  to  ex- 
ploit the  weak  and  unfortunate." 

Streptococcus  infection,  however,  only 
causes  rather  more  than  half  of  the  cases 
of  puerperal  infection  and  its  study  should 
include  that  of  other  organisms.  The 
staphylococcus  is  a  frequently  found  or- 
ganism and,  contrary  to  the  usual  belief,  is 
responsible  for  many  cases  of  puerperal 
endocarditis.  Infection  with  this  organism 
is  not  less  severe  in  type  than  that  from  the 
streptococcus,  as  is  shown  by  Basso  (Gine- 
cologia,  Ap.  30,  1908),  who  collected  a  large 
number  of  cases  with  a  mortality  of  80  per 
cent.  In  fact,  one  of  the  striking  phenom- 
ena of  puerperal  infection  is  the  increase  in 
severity  which  organisms  of  comparatively 
small  virulence,  such  as  the  gonococcus  and 
colon,  may  acquire  and  the  severe  systemic 
symptoms  and  danger  to  life  they  may 
cause.  This  may  be  due  in  part  to  the  les- 
sening of  resistance  to  infection  which  oc- 
curs in  the  pregnant. 

The  whole  tendency  of  research  in  the 
treatment  of  infection  is  toward  chemo- 
therapy as  Ehrlich  said  in  his  address  be- 
fore the  British  Medical  Association.  The 
question  of  treatment  in  puerperal  infec- 
tion is  unsettled  and  will  remain  so  until 
the  ideal  obstetrical  germicide  is  discovered. 
Those  heretofore  used,  such  as  bichloride 
of  mercury  and  formalin,  are  inefficient 
because  they  are  neutralized  by  the  albu- 
minoids of  the  body  tissues  or  discharges: 
others,  such  as  phenol  and  the  cresylic 
acid  preparations,  are  too  poisonous  for 
free  use.  The  idea  that  a  germicide  must 
be  toxic  if  it  is  effective  against  micro- 
organisms is  a  mistaken  one;  otherwise 
chemical  substances  would  be  effective  in 
proportion  to  their  toxicity,  which  is  not  so. 


Page  One  Hundred  Two 


Nor  does  it  explain  the  fact  that  the  same 
substance,  cresol,  for  instance,  may  be 
three  times  more  germicidal  in  emulsion 
than  in  solution,  although  the  toxicity  may 
be  the  same.  The  ideal  obstetrical  germi- 
cide, non-toxic,  efificient  in  the  presence  of 
albuminoids  and  unirritating,  is  not  too 
much  to  hope  for  and  when  it  is  discovered, 
it  will  aid  very  decidedly  in  the  prevention 
and  cure  of  puerperal  infection. 

The  use  of  intra-uterine  douches,  for  ex- 
ample, would  be  put  upon  a  new  basis  if 
such  a  germicide  were  available  to  replace 
such  irritating  substances  as  bichloride  of 
mercury,  formalin  and  the  cresylic  acid 
preparations.  Primo  non  nocere  is  the 
good  old  fashioned  rule  of  a  wise  and 
skeptical  profession  and,  with  this  condi- 
tion fulfilled,  it  might  be  possible  to  do 
many  things  in  puerperal  infection  which 
at  present  are  forbidden. 

But  the  work  of  investigation  should  be 


taken  up  by  the  larger  clinics.  The  estab- 
lishment of  research  foundations  for  the 
study  of  puerperal  infection  would  produce 
more  immediate  results  and  greater  benefits 
to  humanity  than  all  the  cancer  research 
that  has  been  done.  In  spite  of  the  vast 
amount  of  work  that  has  been  done  on 
cancer,  the  hope  of  a  cure  is  no  nearer,  and, 
except  for  the  fact  that  it  has  been  proved 
possible  to  immunize  mice  to  transmissible 
mouse  cancer,  the  research  has  made  but 
little  progress.  Had  a  tithe  of  the  effort 
been  applied  to  puerperal  infection,  it  is 
probable  that  this  plague  would  be  con- 
quered and  the  wail  of  the  motherless  chil- 
dren would  be  banished  from  the  land.  I 
would  that  these  little  voices  in  lamentation 
might  ring  in  the  ears  of  every  obstetrician 
and  pathologist  until  each  is  driven  to  con- 
tribute all  his  energies  and  all  his  efforts  to 
the  salvation  of  the  thousands  of  mothers 
needlessly  sacrificed. 


Page  One  Hundred  Three 


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